O  LIMtAftlES  5 


HEALTH 
SCIENCES 
LIBRARY 


DISORDERS 


MALE  SEXUAL  ORGANS. 


BY 


EUGENE   FULLER,  M.D., 

NEW  YORK  ; 

MEMBER    OF   THE  NEW  YORK  COUNTY  MEDICAL   SOCIETY,  ACADEMY    OF   MEDICINE,   AMERICAN 

ASSOCIATION    OF    GENITO-URINARY  SURGEONS;    INSTRUCTOR  IN   GENITO-URLNARY 

AND  VENEREAL  DISEASES  IN  NEW  YORK  POST-GRADUATE 

MEDICAL    SCHOOL,  ETC. 


PHILADELPHIA: 
LEA    BROTHERS    &    CO. 

189  5. 


Entered  according  to  the  Act  of  Congress,  in  the  year  1895,  by 

LEA  BROTHERS  &  CO., 
In  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PHILADELPHIA  : 
DORNAN,    PRINTER. 


PREFACE. 


Considering  the  importance  of  a  properly  regulated 
sexual  function  to  the  happiness  and  well-being  of  man, 
it  is  remarkable  that  hitherto  so  little  scientific  study 
and  attention  should  have  been  devoted  to  investiga- 
tions upon  that  subject.  It  has  been  and  still  is  quite 
customary  for  the  medical  man,  after  listening  to  the  re- 
cital of  the  complaints  of  one  suffering  from  a  sexual 
disorder,  to  tap  him  on  the  head,  with  the  remark,  "Here, 
my  man,  here  is  the  seat  of  your  trouble."  In  a  certain 
percentage  of  cases  such  a  diagnosis  may  be  correct ;  if 
it  is,  however,  it  is  of  the  "  snap  "  variety,  and  whether 
it  be  correct  or  at  fault,  it  rarely  serves  to  impress  the 
patient,  who  goes  away  either  feeling  that  his  case  has 
been  slightingly  considered,  or  that  his  adviser  is  pos- 
sessed of  little  knowledge.  The  rich  harvest  reaped  by 
advertising  mediums  and  quacks  in  this  department  is 
in  great  measure  due  to  the  unsatisfactory  manner  in 
which  these  cases  are  handled  by  the  regular  profession. 
One  of  the  aims  of  this  work  is  to  show  that  pathologi- 
cal and  physiological  factors  in  connection  with  the 
apparatus  actively  employed  in  the  sexual  act  are  often- 
times the  direct  causes  for  sexual  and  other  allied  dis- 


iv  PREFACE. 

turbances.  In  fact,  it  seems  probable  that  the  factors 
just  mentioned  prevail  in  the  majority  of  these  cases, 
psychological  and  neurotic  conditions,  the  latter  chiefly 
of  a  reflex  nature,  being  in  the  minority.  The  psycho- 
logical side  of  this  question,  the  side  in  fact  which  rep- 
resents by  far  the  smallest  percentage  of  cases,  is  the 
only  one  which  has  been  thoroughly  investigated.  Able 
writers,  among  them  Hammond,  Tarnowsky,  von  Kraflt- 
Ebing,  and  others,  have  so  forcibly  represented  their 
ideas  from  the  standpoint  of  the  alienist  that  the  gen- 
eral reader,  in  the  absence  of  evidence  in  other  direc- 
tions, has  naturally  concluded  that  their  writings  in 
large  measure  cover  the  entire  subject. 

The  neurotic  standpoint  has  been  considered  chiefly 
by  Ultzmann  in  his  work  on  Oenito-  Urinary  Neuroses, 
and  by  Guyon  in  his  article  on  "Sexual  Neurasthenia." 
These  articles,  although  of  much  interest,  and  repre- 
sentative of  accepted  theories,  are,  as  it  will  be  my 
endeavor  to  demonstrate,  really  very  defective  in  that 
practically  all  sexual  disturbances,  aside  from  psycho- 
logical ones,  are  classed  as  neurotic. 

Pathological  and  physiological  factors  are  ignored, 
although  Ultzmann  at  the  end  of  his  book  does  allude 
to  Trousseau,  who  held  as  an  undemonstrated  theory 
that  pathological  conditions  of  the  seminal  vesicles 
accounted  for  the  symptoms  in  some  of  those  cases. 

My  opinion  is  that  trouble  located  in  the  sexual 
apparatus,  and  primarily,  at  least,  largely  independent  of 
nervous  conditions,  is  the  chief  cause  of  sexual  disturb- 
ance in  the  male ;   and  that  the  various  neuroses  and 


PREFACE.  v 

psychological  conditions  stand  in  the  order  named  as 
other  causes. 

It,  therefore,  follows  that  every  case  of  this  nature 
shonld  be  carefully  examined  from  the  three  different 
standpoints  enumerated,  and  a  differential  diagnosis 
given. 

Before  attempting  to  approach  nnderstandingly  the 
main  issue,  it  is  necessary  thoroughly  to  understand 
the  anatomy  of  the  region  under  consideration ;  and  as 
the  general  anatomical  works  have  not  paid  sufficient 
attention  to  this  particular,  it  has  seemed  well  to  devote 
a  chapter  to  that  subject,  in  which,  among  other  things, 
the  mechanism  of  ejaculation  is  considered. 

I  am  greatly  obliged  to  Dr.  James  Ewing,  of  this 
city,  for  his  report  on  the  "  Histology  of  the  Seminal 
Vesicle  and  the  Vas  Deferens,"  which  report  is  annexed 
to  the  chapter  on  Anatomy. 

In  forming  my  plans  and  in  collecting  my  material 
for  this  work  I  have  many  thanks  to  give  to  Dr.  E.  L. 
Xeyes,  with  whom  I  have  been  associated  for  many 
years. 

109  E.  Thiety-foueth  St.,  New  Yoek, 
February,  1895. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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http://www.archive.org/details/disordersofmalesOOfull 


CONTENTS. 


CHAPTEE    I. 

PAGE 

Anatomy 17 


CHAPTEE    II. 
Physiology 49 

CHAPTER    III. 
Pathology 58 

CHAPTER    IV. 

Clinical  Features 80 

CHAPTER    V. 

Differential  Diagnosis 131 

CHAPTER    VI. 

Treatment  and  Prognosis 142 

CHAPTER    VII. 
Illustrative  Instances 180 


DISORDERS 


MALE  SEXUAL  ORGANS 


CHAPTER    I. 

ANATOMY. 

In  order  thoroughly  to  understand  the  subject  about 
to  be  considered,  a  systematic  study  of  the  vesico-rectal 
anatomy  of  the  male  is  essential.  The  term  vesico- 
rectal anatomy  as  used  here  is  intended  to  apply,  first, 
to  the  relation  which  the  bladder  bears  to  the  rectum, 
and  secondly,  to  a  consideration  of  the  important  struc- 
tures which  are  attached  to  or  go  to  make  up  the  vesi- 
cal neck.  These  structures  in  great  measure  may  be 
said  to  occupy  the  recto-vesical  space.  JSTo  attempt 
will  be  made  to  study  the  special  anatomy  of  the  blad- 
der or  of  the  rectum,  or  to  consider  the  general  relations 
which  these  organs  may  bear  to  the  pelvic  structure  or 
to  the  abdominal  organs. 

Should  one  wish  to  acquaint  himself  with  the  medical 
literature  on  this  subject,  including  some  reference  to 
the  embryology  and  comparative  anatomy  of  the  semi- 
nal vesicles  and  the  vasa  deferentia,  he  will  find  such 
information,  together  with  a  full  list  of  references,  in 
Dr.  O.  Guelliot's  excellent  work  Des  Vesicules  SSmi- 
nales,  Anatomie  et  Pathologic,  Paris,  1883,  A.  Coccoz, 
editeur. 

Under  the  first  heading  is  included  the  study  of  the 
fascia  enveloping  the  bladder  and  rectum  in  common, 


18  MALE  SEXUAL    ORGANS. 

its  important  venous  plexus,  and  the  reflexions  of  the 
peritoneum.  Under  the  second  heading  are  included  the 
vasa  deferentia,  the  seminal  vesicles,  the  prostate,  and 
the  deep  urethra,  reference  being  paid  to  the  relation 
which  these  different  parts,  especially  the  vesicles  and 
the  prostate,  bear  not  only  to  one  another,  but  also  to 
the  bladder  proper  and  the  rectum.  As  none  of  the 
anatomical  writers  have  apparently  devoted  themselves 
sufficiently  to  these  particulars,  it  was  found  necessary 
to  make  numerous  dissections  to  illustrate  special  points. 
The  most  important  of  these  dissections  have  been  pho- 
tographed and  reproduced  here,  so  that  exactness  and 
correctness  of  statement  may  be  assured.  These  pic- 
tures have  been  arranged  sequentially,  so  that  a  succes- 
sive study  of  them  together  with  the  accompanying 
description  may  lead  the  reader  on  to  a  thorough  under- 
standing of  the  subject. 

Plate  I.  This  represents  a  dissection  en  masse  of 
the  entire  visceral  contents  of  the  male  pelvis.  This 
mass,  as  is  well  seen  in  the  engraving,  is  securely  bound 
together  by  a  dense  fascia  of  its  own,  which  is  in  its 
turn  connected  by  a  loose  fibrous  meshwork  to  the 
fascia  propria,  which  lines  the  cavity  of  the  pelvis.  It 
is  in  this  loose  fibrous  meshwork  that  extravasated  fluids 
burrow  so  freely.  The  figure  itself  is  about  one-half 
the  natural  size,  with  the  rectum  and  bladder  both  almost 
collapsed.  A  represents  the  anus,  and  B  the  inner  end 
of  the  gut,  section  having  been  made  just  above  the  peri- 
toneal deflection  (see  Plate  IV.).  The  space  between  AB 
shows  the  rectum  in  a  state  of  contraction.  C  is  the 
urethra  in  its  membranous  portion.  D  is  the  bladder. 
E  is  the  prostate.  (The  three  radiating  lines  are  used  to 
designate  the  extent  of  that  organ.)  F  is  the  peritoneum. 
G  points  toward  the  space  lined  by  peritoneum  between 


!> 

— 


> 


ANATOMY.  19 

the  bladder  and  rectum  (see  Plate  IV.).  H'  H"  repre- 
sent respectively  the  anterior  and  posterior  limits  of  the 
pampiniform  plexus,  which  important  group  of  veins 
consists  chiefly  of  two  lateral  plexuses,  one  on  either 
side  of  the  prostato- vesicular  region  entwined  in  the 
meshes  of  the  general  enveloping  fascia.  The  largest 
veins  lie  in  the  crease  between  the  prostate  and  rectum. 
These  lateral  groups  of  veins  communicate  with  one 
another  quite  freely  below  around  the  rectum  and  above 
around  the  urethral  structures.  There  can,  however,  be 
but  little  direct  intercommunication,  through  the  recto- 
vesical space,  between  the  prostate  and  the  rectum,  as  a 
later  dissection  (Fig.  1)  shows  a  lymph-space  in  that 
region  and  an  absence  of  large  veins.  In  removing  this 
dissection  from  the  pelvis  the  firm  attachments  above 
and  below  are  the  only  ones  to  offer  any  real  resistance, 
the  intermediate  space  occupied  by  the  loose  fibrous 
meshwork  being  most  easily  broken  down.  This  loose 
meshwork  allows  of  great  variation  in  size  of  the  pelvic 
contents.  The  attachments  above,  although  firm,  are 
very  elastic,  and  are  made  up  of  the  peritoneum  and  the 
sub-peritoneal  fascia,  which  last  forms  a  connection  with 
the  fascia  propria  of  the  pelvis.  Below  the  attachments 
are  firm  and  strong,  and  those  connecting  the  lower  pros- 
tatic region  with  the  pubic  arch  are  especially  dense 
and  unyielding.  The  attachments  of  the  rectum,  which 
are  partly  muscular  and  partly  fibrous,  have  already 
been  carefully  investigated  by  numerous  anatomists,  and 
do  not  come  within  the  scope  of  this  work. 

Plate  II.  represents  the  other  side,  the  left,  of  Plate  I. 
Here  the  outer  layers  of  the  enveloping  fascia  have  been 
dissected  off,  thus  bringing  into  view  more  distinctly 
the  contour  of  the  different  organs.  The  pampiniform 
plexus   lies   in  the  outer  layers,   and   consequently  no 


20  MALE  SEXUAL  ORGANS. 

longer  appears  in  this  picture.  A,  B,  C,  D,  E,  and  F, 
represent  in  Plate  II.  the  same  as  in  Plate  I.  I  is  the 
left  ureter,  J  the  left  vas  deferens,  K  the  left  seminal 
vesicle.  The  triangle  X,  Y,  Z,  exposing  the  vas  defer- 
ens and  the  seminal  vesicle,  has  been  formed  by  splitting 
apart  the  fibres  of  the  enveloping  fascia,  which  in  this 
region  are  very  firm.  In  the  natural  order  of  things, 
therefore,  the  upper  arm  of  the  triangle,  X  Y,  should  be 
in  fibrous  contact  with  the  lower  arm,  Z  Y,  the  vas  def- 
erens and  the  vesicle  being  hidden  from  view.  It  will 
be  seen  that  the  enveloping  fascia  is  thin  and  delicate 
over  the  bladder  proper,  while  it  is  dense  and  very  strong 
over  the  prostate  and  over  the  prostato-rectal  space. 
Inspection  will,  in  fact,  show  that  this  fascia  is  most 
dense  over  the  prostate  and  very  adherent  to  its  mus- 
cular fibres.  It  is  from  this  portion  of  the  fascia  that 
the  strong  suspensory  ligament  connecting  with  the 
pubic  arch  has  its  insertion.  It  is  well  to  state  here, 
for  the  sake  of  clearness  in  alluding  to  the  prostate,  that 
that  muscular  body,  as  will  be  shown  later  on,  entirely 
encircles  the  vesical  neck,  and  does  not  occupy  simply 
a  position  below  it,  as  seems  to  be  commonly  supposed. 
Radiating  from  the  dense  fascia  covering  the  prostate 
are  numerous  strong  fibrous  bands  extending  backward 
and  downward,  thus  binding  the  prostatic  region  to  the 
bowel  much  more  firmly  than  to  the  bladder  proper. 
Filaments  from  these  fibrous  bands  on  either  side  are 
given  off,  which  envelop  each  seminal  vesicle  in  a  fibrous 
sheath  something  like  the  covering  of  a  cocoon.  Any 
pull  brought  to  bear  on  these  radiating  fibrous  bauds, 
as  it  can  be  seen,  would  occur  during  a  muscular  con- 
traction of  the  prostate,  would  stretch  and  consequently 
narrow  the  sheath  containing  the  seminal  vesicle,  thus 
giving  that  sac  a  squeeze.     This  point  will  be  referred 


PL. 


- 


X 


ANATOMY.  21 

to  later  on  in  considering  the  mechanism  of  ejaculation. 
In  this  figure  the  exposed  seminal  vesicle  seems  to  lie 
below  the  vas  deferens.  This  is  due  to  the  split,  X  Y  Z, 
made  in  the  fascia.  "When  the  edges  of  this  split  are 
drawn  together  the  vesicle  will  be  found  to  have  been 
drawn  up  and  to  lie  outside  of  the  vas  deferens.  In 
Plate  II.,  also,  the  loose  muscular  structures  and  fat 
about  A  and  C  have  been  dissected  off,  exposing  the 
internal  sphincter  and  the  corpus  spongiosum. 

Plate  III.  is  a  rephotograph  of  Plate  II.,  the  only 
difference  being  that  a  cord,  the  insertion  of  which  can 
be  seen,  has  been  tied  to  the  middle  of  the  lower  arm, 
Z  Y,  of  the  triangle,  X  Y  Z,  and  gentle  backward  trac- 
tion applied  so  as  largely  to  obliterate  the  angle  of  the 
triangle  by  bringing  up  the  proximal  half  of  the  lower 
arm  of  fascia  to  its  corresponding  upper  arm.  This  is 
done  to  show  the  reader  more  clearly  the  strong  fibrous 
bands  of  fascia  which  radiate  from  the  prostatic  sheath 
as  well  as  their  true  direction.  It  would,  perhaps,  also 
have  been  well  to  have  attached  another  cord  to  the  end, 
Z,  of  the  lower  arm,  in  order  to  have  shown  the  full 
length  of  these  fibrous  bands ;  but,  with  the  explanation 
at  hand,  such  was  hardly  thought  to  be  necessary. 

Fig.  1  shows  the  neck  of  the  bladder  dissected  off 
from  the  rectum  and  then  drawn  upward,  bringing 
plainly  into  view  the  V-shaped  anterior  recto-vesical 
space  sufficiently  to  expose  the  entire  lower  portion  of 
the  prostate  and  the  base  of  both  seminal  vesicles.  A 
represents  the  rectum,  C  the  urethra,  E  the  lower  por- 
tion of  the  prostate,  K  K  the  bases  of  the  seminal 
vesicles,  L  the  wedge-shaped  fold  of  firm  fascia,  which 
has  been  cut  through  below  the  prostate  and  pulled 
downward,  thus  exposing  to  view  the  bases  of  both 
seminal  vesicles.     M  represents  the  lower  surface  of  the 


22 


MALE  SEXUAL    ORGANS. 


triangular  space,  abd,  the  upper  surface  of  which  is 
made  up  of  the  fascia  covering  the  lower  portion  of  the 
prostate  and  is  represented  by  the  triangle  b  C  d.     The 


Fig.  1. 


Showing  the  lower  portion  of  prostate  and  base  of  the  seminal  vesicle. 

sides  of  these  two  triangles  are  the  cut  edges  of  the 
general  enveloping  fascia.  The  seminal  vesicles  are 
wholly  excluded  from  this  space,  although  in  the  picture 
the  fascia  excluding  them  has  been  cut  through  in  order 


PLATE    IV 


Showing  the  deflections  of  the  pelvic  peritoneum. 


ANATOMY.  23 

to  show  both  their  positions  and  the  posterior  border  of 
the  prostate.  This  triangular  area  is  really  a  lymph- 
space,  allowing  great  mobility  to  the  prostate  with  refer- 
ence to  the  rectum.  There  is  no  venous  plexus  in  con- 
nection with  the  floor  or  roof  of  this  space,  although  in 
cutting  through  the  general  enveloping  fascia  forming 
its  lateral  borders,  a  necessary  procedure  in  making  this 
dissection,  numerous  large  veins  going  to  make  up  the 
pampiniform  plexus  are  wounded.  A  knowledge  of  this 
dissection  is  very  important  in  connection  with  the  oper- 
ation advocated  by  Zuckerkandl  for  the  extirpation  of 
the  seminal  vesicles,  a  subject  which  will  be  considered 
later  on. 

Plate  IV.  is  to  show  the  peritoneum  in  its  connection 
with  the  pelvic  viscera.  A  is  the  anus,  B  is  the  rectum 
cut  across  just  above  the  point  of  peritoneal  deflection. 
The  bladder  is  moderately  distended.  At  the  bottom  of 
the  vesico-rectal  peritoneal  cul-de-sac,  and  to  the  right, 
as  appears  in  the  figure,  a  pin  is  to  be  seen  stuck 
through  the  peritoneum.  The  pin  penetrates  just  above 
the  apex  of  the  left  seminal  vesicle.  This  shows  that, 
although  in  this  dissection  the  peritoneum  at  the  deep- 
est portion  of  the  cul-de-sac  reaches  down  to  the  vesi- 
cle, still  that  it  is  not  deflected  over  that  organ,  and 
cannot  consequently  be  considered  one  of  its  coverings. 
Comparing  this  dissection  with  others,  it  appears  that 
the  peritoneum  rarely  comes  in  closer  contact  with  the 
seminal  vesicle  than  is  shown  in  this  figure,  while  in 
some  instances,  as  will  be  seen  in  considering  Plate  V., 
the  cul-de-sac  is  not  deep  enough  to  allow  of  any  peri- 
toneal contact. 

Plate  V.  Here  B  represents  the  rectum  cut  across 
above  its  peritoneal  deflection.  G  G  point  into  the 
recto-vesical  peritoneal  cul-de-sac,  which  is  represented 


24  MALE  SEXUAL    ORGANS. 

in  a  state  of  moderate  distention,  it  being  packed  with 
cotton-wool.  D  is  the  posterior  wall  of  the  dependent 
bladder,  which  has  been  dissected  off  from  its  peritoneal 
covering,  F,  and  from  the  enveloping  fascia,  E'  E',  which 
last  has  been  cut  away  from  the  sides  of  the  bladder 
and  then  dissected  off  posteriorly.  E  E  are  the  poste- 
rior lateral  borders  of  the  prostate.  The  figure  shows, 
especially  on  its  left  side,  very  distinctly  how  intimately 
the  muscular  fibres  of  the  prostate  at  E  are  blended 
with  bands  of  the  enveloping  fascia  at  E'.  We  have 
already  seen  in  Plates  II.  and  III.  an  outside  view  of 
this  same  blending.  It  can  also  be  seen  to  a  certain 
extent  how  each  vesicle  lies  imbedded  in  a  fibrous 
sheath  (allusion  to  which  has  already  been  made  in 
studying  Plate  II.),  which  sheath  is  attached  to  and 
made  up  of  the  firm  bands  of  the  enveloping  fascia 
which  radiate  backward  and  downward  from  the  pros- 
tatic covering.  Two  cords  attached  to  the  upper  cut 
edges  of  the  elastic  enveloping  fascia,  and  exerting 
moderate  lateral  traction,  are  sufficient  to  roll  back  the 
fibrous  sheaths  that  have  already  been  dissected  oif  the 
vesicles,  and  consequently  to  expose  the  anterior  sur- 
faces of  those  organs  which  otherwise  would  have  been 
hidden  from  view  in  a  dissection  such  as  this  one.  I  is 
the  right  ureter.  G'  shows  the  bottom  level  of  the 
vesico-rectal  peritoneal  cul-de-sac.  On  each  side  the 
limits  of  this  cul-de-sac  are  marked  by  the  vasa  defer- 
entia.  So  in  this  dissection  the  peritoneum  does  not 
come  in  contact  at  all  with  the  seminal  vesicles.  An- 
other point  which  this  figure  shows  is  the  slightness  of 
the  attachment  of  the  bodies  of  the  seminal  vesicles 
to  the  posterior  wall  of  the  bladder,  and  at  the  same 
time  the  firmness  with  which  they  are  bound  to  the 
prostate  and  to  the  sheath  of  the  rectum,  thus  allowing 


PLATE    V. 


Showing  the  vesicles  in  their  fibrous  sheaths,  the  bladder  having 
been  dissected  off  and  turned  downward. 


ANATOMY. 


25 


them  little  or  no  motion  independent  of  the  prostate. 
This  is  important,  for  otherwise,  if  the  body  of  the 
vesicle  could  move  independently  of  the  prostate  there 
would  result  a  bending  of  the  ejaculatory  ducts  just 
posteriorly  to  their  entrance  into  the  prostatic  body  such 
as  would  necessarily  interfere  with  the  ejaculatory  act. 

Fig.  2. 


Posterior  wall  of  the  bladder  showing  vesicles  and  prostate. 


Fig.  2  (much  reduced  in  size)  shows  the  posterior 
Avail  of  the  bladder  and  a  posterior  view  of  the  seminal 
vesicles  and  the  prostate,  all  the  enveloping  fascia  hav- 
ing been  dissected  off.     C,  as  usual,  marks  the  urethra, 


26  MALE  SEXUAL   ORGANS. 

E  the  prostate,  K  the  seminal  vesicle,  I  the  ureter,  and 
J  the  vas  deferens.  The  posterior  Y-shaped  vesical 
space  between  the  diverging  vasa  deferentia,  through 
which  recto-vesical  puncture  for  relief  of  retention  of 
urine  is  sometimes  made,  is  very  distinct.  The  so-called 
lateral  lobes  of  the  prostate  show  up  well  together  with 
the  deep  intermediate  sulcus,  in  the  bottom  of  which  are 
the  two  vasa  deferentia,  which  here  come  so  closely  to- 
gether that  they  touch.  It  will  be  seen  in  examining 
the  lateral  lobes  of  the  prostate  that  they  have  no  de- 
fined posterior  border,  but  that  the  muscular  fibres  which 
compose  them  extend  backward  and  become  so  blended 
with  the  musculo-fibrous  tissue  constituting  the  lower 
portion  of  the  seminal  vesicles  that  it  is  impossible  to 
say  just  where  one  ends  and  the  other  begins.  If  these 
muscular  bands  which  extend  back  from  the  prostate  to 
the  wall  of  the  vesicle  are  observed  carefully,  it  will  be 
seen  that  their  fibres  are  so  arranged  that  when  a  pros- 
tatic muscular  contraction  takes  place  there  would  be 
exerted  a  strong  pull  on  the  lower  half  of  the  vesicle, 
which  pull  would  be  sufficient,  if  coincident  with  a 
tightening  of  the  fibrous  sheath  of  the  vesicle,  such  as 
we  have  seen  in  Plates  II.  and  III.  would  result  from  a 
contraction  of  the  lateral  and  upper  portions  of  the  pros- 
tate, to  give  the  whole  seminal  vesicle  a  strong  squeeze. 
It  is  reasonable  to  suppose  when  such  a  muscular  contrac- 
tion takes  place  in  the  prostatic  body,  that  it  is  general 
in  character,  thus  exerting  pressure  over  the  whole  area 
of  the  vesicle.  The  posterior  lateral  lobe  of  the  prostate 
is  evidently  a  grouping  of  muscular  fibres  arranged 
especially  to  exert  traction  on  the  corresponding  seminal 
vesicle.  Subsequent  figures,  especially  Plate  VI.  and 
Fig.  7,  as  will  be  seen,  support  this  statement.  Exami- 
nation will  show  that  the  contour  of  the  seminal  vesicle 


ANATOMY. 


27 


is  not  regular,  such  as  one  would  expect  if  the  interior 
consisted  of  a  single  oblong  chamber,  but  that  it  is 
irregular,  presenting  an  appearance  similar  to  that  of  an 


Fig.  3. 


Posterior  wall  of  tile  bladder,  showing  the  vesicles  in  their  fibrous  sheaths. 

oblong  bag  into  which  had  been  crowded  a  flexible 
cylindrical  body.  The  reason  for  this  appearance  will 
be  evident  later  on  in  studying  Fig.  7.     The  distal  por- 


28  MALE  SEXUAL   ORGANS. 

lions  of  the  vasa  deferentia,  as  can  be  seen,  are  con- 
siderably smaller  in  circumference  than  the  proximal 
portions  where  they  converge.  Attention  will  again 
be  called  to  this  point  later  on. 

Fig.  3  (much  reduced  in  size)  represents  a  dissection 
quite  similar  to  that  of  Fig.  2.  Here,  however,  the 
peritoneum,  F,  has  been  only  partially  dissected  up  from 
the  posterior  vesical  wall  and  the  vasa  deferentia,  J  J, 
have  not  been  dissected  free  from  it.  The  general  en- 
veloping fascia  also  has  not  been  removed  so  freely,  and 
at  E'  E'  it  is  plainly  seen  showing  its  intimate  attach- 
ment to  the  prostate.  Its  connection  with  the  bodies  of 
the  vesicles  does  not  appear  here,  as  these  organs  have 
been  dissected  from  their  fibrous  sheaths.  It  is  well  to 
examine  the  fascia,  E'  E',  in  this  figure,  in  connection 
with  the  same  fascia,  E'  E',  in  Plate  Y.  In  Fig.  3 
the  fascia  has  been  cut  through  behind  the  seminal 
vesicles,  while  in  Plate  V.  the  cut  has  been  in  front  ot 
them.  The  vertical  furrow  in  the  base  of  the  prostate 
is  due  to  an  accidental  cut  into  the  muscular  substance 
of  that  body. 

Fig.  4  is  the  same  as  Fig.  2,  except  that  in  Fig.  4 
the  dissection  is  completed  so  as  fully  to  expose  the 
lower  portions  of  the  seminal  vesicles  and  the  ejacula- 
tory  ducts.  This  has  been  accomplished  by  dissecting 
off  the  musculo-fibrous  attachments  of  the  prostate  from 
the  lower  portions  of  the  vesicles,  and  then,  by  splitting 
across  transversely  in  the  line  of  the  ejaculatory  ducts 
down  to  the  prostatic  urethra,  the  lower  portion  of  the 
posterior  prostatic  body  from  the  upper  portion.  The 
free  dissected  portion  of  the  prostate  is  then  rotated 
vertically  downward.  C  represents  the  under  portion  of 
the  floor  of  the  prostatic  urethra  in  the  neighborhood  of 
the  caput  gallinaginis,  on  either  side  of  which  the  ejacu- 


ANATOMY. 


29 


latory  ducts  communicate  with  the  urethra.  Ea  Ea 
represent  the  anterior  section  of  the  prostatic  lobes,  Eb 
Eb  the  posterior  section,  which  has  been  rotated  from 

Fig.  4. 


Eb 


Posterior  wall  of  the  bladder,  showing  the  ejaculatory  ducts. 

Ea  Ea,  with  C  as  an  axis,  180°  downward.  The  semi- 
nal vesicles  in  their  entire  length,  the  junction  of  the 
vas  deferens  with  its  vesicle  and  the  ejaculatory  ducts 


30  MALE  SEXUAL   ORGANS. 

lying  parallel  and  in  close  apposition,  appear  quite 
plainly.  The  ejaculatory  ducts,  although  entirely  inde- 
pendent of  one  another,  are  firmly  bound  together  in  a 
common  fibrous  sheath,  which  has  been  largely  dissected 
away  in  this  figure  in  order  to  show  their  individuality. 
This  sheath,  however,  has  been  left  intact  in  Fig.  5. 
The  common  sheath  containing  the  ejaculatory  ducts  is 
not  attached  laterally  to  the  muscular  substance  of  the 
prostate,  but  lies  free  in  a  lymph-space  the  walls  of 
which  consist  of  another  and  larger  fibrous  sheath  in- 
corporated into  the  substance  of  the  prostate.  This 
larger  sheath  has  been  called  the  infundibulum  of  the 
prostate.  ZiST  ET  show  the  roof  of  the  infundibulum,  and 
N'  shows  its  floor.  The  walls  of  the  ejaculatory  dncts 
are  very  elastic.  It  is  thus  evident  that  when  the  mus- 
cular fibres  of  the  prostate  contract,  causing  a  direct 
pull  on  the  body  of  the  vesicle,  that  the  length  of  the 
ejaculatory  ducts,  by  reason  of  their  lying  free  in  a 
lymph-space,  is  shortened,  their  walls  relaxed,  and  the 
capacity  of  their  canals  increased. 

Fig.  5  shows  the  posterior  view  of  the  vasa  defer- 
entia,  the  seminal  vesicles  and  their  ducts,  together  with 
the  small  section  of  the  urethra  which  includes  the 
openings  of  the  ducts.  The  left  vas  deferens  and  ves- 
icle are  normal  in  size  and  natural  in  appearance;  the 
right,  however,  happens  to  be  in  a  state  of  atrophy, 
which  condition  will  be  alluded  to  later  on  in  consider- 
ing the  pathology  of  the  parts.  The  increased  circum- 
ference of  the  lower  portion  of  the  normal  vas  deferens 
over  the  upper  distal  portion  is  clearly  brought  to  view. 
In  this  lower  portion,  also,  the  cord  is  not  cylindrical, 
but  is  somewhat  flattened  on  its  anterior  and  posterior 
surfaces.  In  this  figure  the  common  sheath  envelop- 
ing the  ejaculatory  ducts  has  been  left  intact,  so  bind- 


ANATOMY. 


31 


ing  them  together  as  to  give  the  appearance  of  a  single 
duct  rather  than  two.  Each  duct  has  been  catheterized 
through  its  urethral  opening  by  means  of  a  bristle, 
which,  however,  does  not  appear  in  this  figure.  Each 
bristle  passes  upward  and  outward,  entering  the  cavity 

Fig.  5. 


The  vasa  deferentia,  the  seminal  vesicles  and  their  ducts. 


of  the  corresponding  seminal  vesicle,  and  by  no  amount 
of  manipulation  was  it  found  possible  to  make  one  of 
these  bristles  enter  the  canal  of  the  vas  deferens.  Fig. 
7  will  also  show  that  the  bristles  by  entering  the  cavity 
of  the  seminal  vesicles  took  their  natural  course. 


32 


MALE  SEXUAL   ORGANS. 


Fig.  6  is  chiefly  to  show  the  floor  of  the  prostatic 
urethra.  To  accomplish  this  a  cut  has  been  made 
through    the   roof  of    the    membranous    and   prostatic 


Fig.  6. 


The  floor  of  the  prostatic  urethra. 


urethra,  and  extending  backward  through  the  lower 
portion  of  the  anterior  bladder-wall.  The  cut  edges 
have  then  been  moderately  separated.     O  represents  the 


> 


ANATOMY.  33 

posterior  median  limit  of  the  trigonum ;  E,  the  upper 
portion  of  the  prostate;  C,  the  membranous  urethra. 
Back  of  this  is  the  prostatic  urethra.  In  the  median 
longitudinal  line,  the  elevated  ridge  of  which  is  seen,  is 
the  caput  gallinaginis  or  verumontanum  with  the  par- 
allel depressions  on  either  side.  Those  depressions  form 
the  prostatic  sinus.  At  about  the  middle,  and  on  the 
summit  of  the  caput  gallinaginis,  is  a  little  oval,  flat- 
tened area,  with  edges  quite  well  defined.  This  is  the 
sinus  procularis,  and  it  is  in  the  forward  sides  of  this 
body  that  the  openings  into  the  ejaculatory  ducts  are 
situated.  The  sinus  procularis  is  small  and  hard  to  show 
in  a  photograph.  Still,  careful  inspection  will  make  it 
out  mostly  posterior  to  the  pointers,  PP,  which  mark 
the  mouths  of  the  two  ejaculatory  ducts.  Attention  is 
called  to  the  thickness  of  the  prostate  above  the  urethra. 
This  arrangement  of  the  prostate,  however,  will  be  taken 
up  more  particularly  in  Plate  VT. 

Plate  VI.  represents  a  longitudinal  section  through 
the  vesical  neck.  To  accomplish  this  two  vertical  cuts 
have  been  made.  The  upper  one  above  the  urethra  and 
bladder  divides  the  structures  in  the  median  line.  The 
lower  one  is  not  in  the  median  line,  but  to  one  side,  pass- 
ing along  the  prostatic  sinus.  The  smaller  section  has 
been  pulled  back  out  of  view,  so  the  picture  represents 
the  larger  one.  The  seminal  vesicle  which  shows  is  the 
outer  side  of  the  left.  This  vesicle  projects  consider- 
ably beyond  the  line  of  the  lower  vertical  incision,  which 
has  cut  through  the  lower  wall  of  the  bladder  just  above 
it,  and  it  would  have  been  in  large  measure  removed 
with  the  smaller  section  had  the  lower  vertical  cut  been 
carried  downward  sufficiently  to  reach  it.  Q  is  the  band 
of  fascia  which  marks  the  posterior  limits  of  the  pros- 
tate above  the  vesical  neck.     The  elevated,   flattened 

3 


34  MALE  SEXUAL  ORGANS. 

area,  the  sinus  procularis,  extending  along  the  summit 
of  the  caput  gallinaginis,  shows  up  in  Plate  VI.  rather 
better  than  in  Fig.  6.  A  study  of  the  upper  and  lower 
sections  through  the  prostate  is  most  instructive,  for  it 
shows  not  only  that  that  structure  encircles  the  vesical 
neck,  but  also  that  about  as  much  of  it  lies  above  the 
prostatic  urethra  as  below  it.  In  other  words,  this  body 
occupies  the  position  of  a  broad  muscular  ring  about 
the  neck  of  the  bladder.  The  upper  portion  of  this  en- 
circling band  is  seen  to  be  placed  relative  to  the  urethra 
somewhat  anterior  to  the  lower  portion.  The  convoluted 
contour  of  the  seminal  vesicle  is  distinct,  together  with 
the  bands  of  prostatic  muscular  fibre  which  are  inserted 
into  its  lower  portion.  1ST  marks  a  fibrous  line  which 
extends  through  the  lower  section  of  the  prostate.  This 
fibrous  line  is  the  outer  wall  of  the  prostatic  fibrous 
sheath,  the  infundibulum,  which,  as  we  have  already 
seen  in  Fig.  4,  encircles  the  ejaculatory  ducts  as  they 
pass  enveloped  in  their  own  common  sheath  through  the 
prostate.  These  two  sheaths  are,  as  also  seen  in  Fig.  4, 
separated  from  one  another  by  a  lymph-space.  The 
direction  of  the  fibrous  line,  N",  from  the  seminal  vesicle 
toward  the  anterior  portion  of  the  caput  gallinaginis 
shows  the  course  of  the  ejaculatory  ducts  and  to  what 
extent  they  are  imbedded  in  the  prostate.  The  space 
between  the  fibrous  sheath  covering  the  body  of  the 
seminal  vesicle  and  the  lower  bladder- wall  is  seen  to  be 
filled  with  delicate  connective  tissue,  which  in.  fleshy  in- 
dividuals contains  much  fat.  In  fact,  tissue  such  as  this 
fills  in  all  the  otherwise  vacant  places  in  the  recto-vesical 
space  posterior  to  the  prostate,  serving  the  purpose,  as 
it  were,  of  a  packing-material.  In  most  of  the  engrav- 
ings representing  this  space  this  delicate  connective 
tissue  has  been  removed  in  order  to  make  the  dissection 


AXATOMY. 


35 


distinct.  A  consideration  of  this  connective  tissue  be- 
comes important  in  certain  inflammatory  conditions,  as 
will  be  seen  in  studying  the  pathology  of  this  region. 


Fig.  7. 


View  of  the  interior  of  the  seminal  vesicle  and  of  its  ejaculatory  duct. 


The  median  posterior  position  occupied  by  the  ejacula- 
tory ducts,  as  seen  in  this  Plate  (VI.)  as  well  as  in  Fig.  4, 
shows  how  impossible  it  would  be  to  wound  these  parts 
in  the  operation  of  lateral  lithotomy.     This  is  important, 


36  MALE  SEXUAL  ORGANS. 

as  the  chance  of  wounding  them,  especially  in  children, 
has  been  one  of  the  stock  arguments  for  many  years 
advanced  against  this  surgical  procedure. 

Fig.  71  (somewhat  below  the  normal  size)  shows  the 
interior  of  a  seminal  vesicle  and  the  commencement  of 
its  ejaculatory  duct.  An  incision  has  been  made  into 
the  connecting  vas  deferens  and  the  shaft  of  an  ordinary 
sized  hair-pin  forced  down  its  duct.  The  end  of  the 
hair-pin  shows  in  the  picture  protruding  through  the 
entrance  of  the  vas  deferens  into  its  vesicle.  This  en- 
trance is  round  and  just  large  enough  to  allow  the  shaft 
of  the  hair-pin  to  pass  through  easily.  Above  this 
entrance,  for  an  inch  to  an  inch  and  a  half,  the  calibre  of 
the  canal  of  the  vas  deferens  is  somewhat  larger — prob- 
ably large  enough  to  take  a  catheter  twice  the  calibre 
of  the  hair-pin.  This  enlarged  area  has  been  called  the 
ampulla  of  Henle.  Higher  up  than  this,  however,  the 
canal  grows  much  smaller,  so  that  the  shaft  of  an  ordi- 
nary dress-pin  is  a  tight  fit.  At  the  very  top  of  the 
figure,  just  above  the  apex  of  the  seminal  vesicle,  a 
small  section  of  the  shaft  of  the  hair-pin  can  be  indis- 
tinctly seen  as  it  penetrates  the  vas  deferens.  At  this 
point,  however,  the  duct  was  not  large  enough  to  admit 
of  the  passage  of  the  hair-pin  shaft  without  being  ex- 
tensively ruptured,  and  this  rupture  extended  for  some 

1  The  anatomical  descriptions  of  the  different  ones  who  have  investi- 
gated the  part  illustrated  by  Fig.  7  can  be  found  in  the  work  of  Dr.  O. 
Guelliot,  Des  Vesicules  Serninales  Anatomie  et  Pathologie,  Paris,  1883, 
Those  descriptions  are  more  or  less  indefinite  and  conflicting.  It  is,  there- 
fore, probable  that  there  may  be  some  variation  in  minor  details,  such  as 
in  the  number  of  the  diverging  canals,  their  exact  course,  etc.,  with  different 
individuals.  Still,  in  the  several  cases  I  have  dissected  much  tbe  same 
condition  as  is  here  depicted  has  been  discovered.  In  making  dissections  I 
have  found,  if  one  makes  the  attempt  by  first  opening  the  diverging  canals, 
and  then  secondarily  the  main  cavity,  that  considerable  confusion  as  to  the 
exact  relative  position  of  the  parts  is  liable  to  result. 


ANATOMY.  37 

distance  downward  before  the  canal  became  large  enough 
to  admit  it.  The  circumference,  as  has  already  been 
alluded  to,  of  the  walls  of  the  vas  deferens  near  its  ter- 
mination is  much  increased.  A  section  through  the 
structure  in  this  part,  however,  will  show  that  the  in- 
crease in  circumference  is  due  in  much  greater  measure 
to  an  increase  in  the  thickness  of  the  walls,  which  have 
here  become  very  muscular,  rather  than  to  a  marked  in- 
crease in  the  calibre  of  the  canal.  The  inside  lining  of 
the  canal  of  the  vas  deferens  in  its  lower  enlarged  por- 
tion is  not  smooth,  but  interwoven  with  muscular  tra- 
becule much  the  same  as  the  figure  shows  exists  in 
connection  with  a  large  part  of  the  inner  surface  of  the 
seminal  vesicles.  The  view  of  the  inner  surface  of  the 
right  seminal  vesicle  as  seen  in  this  figure  was  ob- 
tained by  making  a  longitudinal  cut  through  its  poste- 
rior wall  and  through  the  posterior  wall  of  the  upper 
portion  of  its  ejaculatory  duct.  The  intervening  pros- 
tatic structures  were  also  included  in  the  cut.  The  walls 
thus  cut  through  were  gently  separated  and  held  apart 
by  the  insertion  through  their  edges  of  numerous  pins. 
The  upper  part  of  the  cavity  thus  exposed  is  seen  to  be 
larger  than  the  lower  portion  and  its  walls  less  thick. 
In  connection  with  the  upper  part  of  the  cavity  are  seen 
three  large  holes,  each  of  which  has  been  stuffed  with 
cotton.  These  three  holes  mark  the  openings  into  three 
canals  of  various  lengths  and  directions,  each  of  which 
finally  ends  in  a  blind  sac.  The  two  lower  canals  open 
into  the  upper  portion  of  the  cavity  of  the  vesicle  on  its 
anterior  surface.  The  upper  canal  really  opens  into  the 
apex  of  the  vesicular  cavity.  Such  does  not  at  first 
sight  seem  to  be  the  case  in  this  figure.  This  is  because 
the  vertical  cut  has  been  extended  upward  somewhat 
beyond  the  apex  of  the  cavity  of  the  vesicle,  thus  split- 


38  MALE  SEXUAL  ORGANS. 

ting  open  the  true  mouth  of  this  canal.  Then,  besides 
the  top  pin  exercising  some  traction  pulls  up  the  upper 
wall  of  the  canal.  These  two  factors  go  not  only  to 
make  the  true  cavity  of  the  vesicle  appear  to  be  a  little 
longer  than  it  should,  and  to  be  peaked  rather  than 
rounded,  but  also  to  make  the  opening  of  the  upper  canal 
appear  lateral  rather  than  as  it  is,  vertical ;  consequently 
the  upper  cotton  plug  is  not  really  in  the  mouth  of  the 
canal,  as  in  the  other  two  cases,  but  somewhat  farther 
in.  These  slight  changes  were  necessary  in  order  suc- 
cessfully to  photograph  the  dissection.  These  canals 
are  lined  by  a  delicate  secreting  membrane.  They  are 
in  the  neighborhood  of  half  an  inch  to  an  inch  in  length, 
and  so  convoluted  that  should  they  be  carefully  dis- 
sected out  they  would  appear  much  longer,  and  with, 
in  some  instances,  diverticula.  In  tracing  them  from 
their  mouths  to  their  source  it  is  found  that  the  upper 
one  from  its  downward  opening  makes  a  sharp  upward 
arch,  and  then  extends  abruptly  downward  again  for  a 
considerable  distance  along  the  front  surface  of  the  ves- 
icle. The  large  outer  canal  just  below  this  one  main- 
tains throughout  its  entire  course  a  general  downward 
trend.  The  smaller  inward  canal  runs  upward,  and  is 
the  shortest  of  the  three.  Below  these  are  a  number  of 
small  diverticula  leading  off  from  the  cavity  of  the  ves- 
icle for  very  short  distances.  They  are  too  small,  how- 
ever, to  be  specially  mentioned  as  canals.  It  is  easy 
now  to  understand  the  peculiar  outside  contour  of  the 
vesicle,  attention  to  Avhich  has  already  been  called.  The 
main  cavity  of  the  vesicle  is  seen  to  resemble  in  some 
respects  the  pelvis  of  the  kidney.  Its  lateral  walls  are 
firm  and  strong,  and  below  the  openings  of  the  large 
canals  downward  two-thirds  of  the  way  to  the  opening 
of  the  duct  of  the  vas  deferens  their  inner  surfaces  are 


ANATOMY.  39 

interwoven  with  strong  muscular  trabecule  resemb- 
ling the  inner  walls  of  the  cardiac  ventricles.  About 
the  mouth  of  the  vas  deferens  and  below  it,  however, 
their  inner  lining  is  perfectly  smooth.  The  lower  half  of 
the  vesicular  wall  is  very  thick  and  muscular.  This  is 
well  seen  in  the  outer,  but  not  so  well  in  the  inner  sec- 
tion, as  the  latter  is  in  shadow.  The  intimate  associa- 
tion of  the  prostate  with  the  lower  portion  of  this  mus- 
cular wall  is  also  evident.  The  cavity  of  the  vesicle  is 
seen  to  be  largest  above  in  the  space  into  which  the  canals 
empty,  and  from  there  gradually  to  decrease  in  size  until 
the  ejaculatory  ducts  are  reached.  The  natural  calibre 
of  the  ejaculatory  ducts  is  considerably  smaller  than 
that  of  the  hair-pin  which  projects  through  the  opening 
of  the  vas  deferens,  but  their  walls  are  elastic  and  can 
be  stretched  to  that  calibre.  Their  urethral  openings, 
also,  are  so  small  as  only  to  be  seen  on  careful  inspec- 
tion ;  but  these  too  are  capable  of  considerable  enlarge- 
ment on  necessary  occasions.  The  calibre  of  the  open- 
ing of  the  vas  deferens  is  seen  to  be  very  much  smaller 
than  that  of  the  seminal  vesicle  at  its  point  of  entrance. 

The  object  of  the  anatomical  investigation  just  com- 
pleted has  been  to  render  the  subject-matter  of  the 
succeeding  chapters  the  more  intelligible.  In  striving 
to  attain  this,  however,  certain  other  points  of  impor- 
tance have  been  revealed.  Although  foreign  to  the  pur- 
pose of  this  work,  it  has  seemed  well  to  recapitulate 
some  of  them  briefly. 

The  Pampiniform  Plexus.  Although  the  exact  location 
of  this  plexus  is  not  very  well  fixed  in  the  popular  pro- 
fessional mind,  still  it  has  been  commonly  supposed  to 
envelop  the  lower  surface  of  the  prostate.  This,  as  has 
been  seen,  is  not  the  case,  but  that  its  principal  focus  is 
in  the  enveloping  fascia  and  lateral  to  that  body. 


40  MALE  SEXUAL  ORGANS. 

The  Prostate  Gland.  The  ordinary  anatomical  descrip- 
tion of  this  body  has  been  that  it  is  about  the  size  and 
shape  of  a  horse-chestnut ;  that  it  lies  between  the  rectum 
and  the  neck  of  the  bladder ;  and  that  it  consists  of  two 
lateral  lobes.  With  this  description  in  mind,  it  has  been 
common  to  imagine  that  the  whole  gland  might  be  re- 
moved by  a  perineal  incision  such  as  Von  Dittel  has 
advocated  for  some  instances  of  prostatic  hypertrophy. 
In  fact,  reports  of  the  removal  of  the  entire  prostate  by 
this  procedure  have  appeared.  It  is,  however,  a  circular 
muscle  surrounding  the  vesical  neck  and  intimately  con- 
nected with  the  seminal  vesicles,  its  muscular  evidently 
greatly  predominating  over  its  glandular  function. 

The  Position  of  the  Ejaculatory  Ducts  with  Reference  to 
Lithotomy.  As  has  been  shown,  the  position  of  these 
ducts  is  such  that  there  is  no  danger,  or  in  fact  possi- 
bility, of  their  being  cut  in  the  operation  of  lateral 
lithotomy.  They  may,  however,  be  injured  in  the  oper- 
ation of  median  lithotomy  or  of  perineal  section,  where 
the  backward  cut  is  too  extensive. 


THE  REPORT  OF  DR.  JAMES  BWING  ON  THE  HIS- 
TOLOGY OF  THE  SEMINAL  VESICLE  AND  THE 
VAS  DEFERENS. 

The  following  description  of  the  histology  of  the  am- 
pulla of  Henle  and  the  seminal  vesicles  is  based  upon  a 
study  of  twelve  specimens,  selected  from  males  whose 
ages  ranged  from  twenty  to  forty-five  years,  and  in 
which  these  organs  presented  no  apparent  pathological 
changes. 

The  wall  of  the  ampulla  presents  for  examination 
fibrous,  muscular,  and  mucous  layers.  The  fibrous  coat 
consists  of  several  lamella  of  loose  fibrous  tissue  inclos- 


AXA  TOJIY. 


41 


ing  many  bloodvessels,  lymphatics,  and  gangliated  nerve- 
cords.  At  the  lower  end  of  the  ampulla  this  fibrous 
tissue  unites  with  the  similar  investment  of  the  vesicle, 
its  lamellae  being  separated  by  many  longitudinal  and 
transverse  muscle-bundles,  and  finally  it  becomes  merged 
in  the  fibro-muscular  capsule  of  the  prostate  gland. 


Fig.  8. 


Epithelium  of  upper  ampulla. 

In  the  muscular  wall  of  the  ampulla  the  arrangement 
of  the  fibres  varies  with  the  level  at  which  the  section  is 
made.  Over  the  upper  two-thirds  of  the  ampulla  two 
distinct  layers  may  be  distinguished,  an  outer  longitu- 
dinal and  an  inner  transverse  one.    From  the  inner  layer 


42 


MALE  SEXUAL  ORGANS. 


are  derived  the  fibres  which  form  the  numerous  rugae 
and  anastomosing  trabecule  which  project  into  the 
lumen  of  the  dilated  canal.     At  the  lower  end  of  the 


Fig.  9. 


Upper  ampulla. 
Oblique  view  from  above,  showing  clefts  between  tip  of  cells. 

ampulla,  although  the  division  into  longitudinal  and 
transverse  coats  is  still  partially  retained,  the  separation 
of  the  layers  is  less  perfect,  many  longitudinal  and 
oblique  fibres  being  scattered  through  the  trans  verse 
coat  and  the  longitudinal  bundles  not  being  continuous 
throughout   the    entire    circumference  of  the  ampulla. 

Fig.  10. 


Epitbelium  of  the  tip  of  the  ampulla. 

Many  of  these  fibres  of  the  ampulla,  as  well  as  in  the 
wall  of  the  vesicle  and  ejaculatory  duct,  are  found  dis- 
colored by  grains  and  globules  of  pigment. 


ANATOMY.  43 

The  mucosa  of  the  ampulla  consists  of  one  layer  of 
high  columnar,  non-ciliated  cells  resting  upon  a  layer  of 
triangular  or  cuboidal  cells,  and  supported  by  an  indis- 
tinct membrana  propria.  The  total  area  of  exposed 
epithelial  surface  is  very  greatly  increased  by  the  fibro- 
muscular  ridges  and  trabecule  which  rise  in  three  or 
four  tiers  from  the  transverse  muscular  layer.  The  epi- 
thelial surface,  therefore,  presents  innumerable  depres- 
sions, and  many  diverticula  are  seen  in  cross-section 
which  might  be  regarded  as  curved  tubular  glands, 
although  the  secreting  power  of  the  cells  is  not  much 
more  manifest  here  than  in  other  parts  of  the  mucosa. 

Fig.  11. 


Epithelium  of  the  end  of  the  ampulla. 

Examined  under  high  magnification  (1/12  oil  immer- 
sion), either  freshly  teased  in  glycerin  or  in  stained 
sections,  the  cylindrical  cells  show  some  striking  pecu- 
liarities. Their  length  varies  from  1/100  to  1/50  of  a 
millimetre,  the  longer  cells  being  derived  from  the  de- 
pressions and  diverticula.  In  outline  they  are  irregu- 
larly conical,  with  long  fan-shaped  or  club-shaped  tips, 
and  short  pointed  extremities  fitting  the  interstices  of 


44 


MALE  SEXUAL  ORGANS. 


the  second  row  of  triangular  or  euboidal  cells.     The 
nuclei  are  large  oblong  or  elliptical  masses  situated  at 


Fig.  12. 


Individual  cells  from  the  tip  of  the  vesicle. 


Fig.  13. 


Superficial  and  deep  epithelium  from  the  tip  of  the  vesicle. 


or  below  the  middle  of  the  cell-body,  and  produce  a  dis- 
tinct bulging  of  the  outline.     The  protoplasm  is  finely 


ANATOMY. 


45 


granular  and  strongly  eosinophile,  except  at  the  project- 
ing tip,  where  the  cell-body  is  translucent  and  nearly 
devoid  of  granules.  In  this  clearer  portion  of  the  cell 
many  transparent  vacuoles  may  always  be  seen  which 


Fig.  14. 


Epithelium  from  a  deejo  alveolus  near  the  tip  of  the  vesicle. 


respond  to  the  tests  for  mucus.     The  uniform  distribu- 
tion of  the  mucus-globules  leaves  no  doubt  of  the  secre- 


Fig.  15. 


Epithelium  from  a  deep  diverticulum  near  the  middle  of  the  vesicle. 


tory  function  of  the  entire  epithelial  surface  of  the  am- 
pulla. In  addition  to  the  globules  of  mucus,  grains  and 
masses  of  brownish  pigment  are  very  constantly  found  in 
the  same  portion  of  the  cell,  but  limited  frequently  to  the 


46  MALE  SEXUAL  ORGANS. 

protoplasm  along  the  inner  border  of  the  nucleus.  This 
pigment  is  identical  in  appearance  with  that  found  in  the 
smooth  muscle-fibres.  In  the  diverticula  of  the  mucosa, 
where  the  cells  are  somewhat  higher  than  on  the  exposed 
portions  of  the  canal,  the  mucus-globules  and  pigment- 
masses  are  slightly  more  numerous.  Throughout  the 
ampulla,  the  vesicle,  and  the  upper  part  of  the  ejacula- 
tory  duct  this  pigment  is  so  abundant  as  to  produce  a 
brownish  discoloration  of  the  mucosa  that  is  plainly 
visible  to  the  naked  eye.  Prolonged  staining  with  osmic 
acid  developed  a  black  granule  in  the  centre  of  many  of 

Fig.  16. 


Epithelium  of  the  lower  portion  of  the  ejaculatory  duct. 

the  pigment-globules,  thus  showing  the  fatty  nature  of 
at  least  a  portion  of  the  masses.  Their  composition 
was  not  further  explained  by  treatment  with  many 
aniline-dyes,  nor  by  tests  for  iron  or  glycogen. 

The  fibrous  coat  of  the  seminal  vesicles  is  very  similar 
to  that  of  the  ampulla,  and  needs  no  further  description. 

In  the  muscular  coat  it  is  difficult  to  follow  the  course 
of  the  fibres  for  any  length,  and  at  many  points  along  the 
base  of  the  vesicle  it  is  often  impossible  to  distinguish 
any  well-defined  layers.  At  the  summit  of  the  vesicle, 
however,  four  distinct  layers  may  often  be  separated. 
Of  these,  the  two  outer  may  be  demonstrated  to  pass 
from  one  pouch  to  another,  while  the  inner  layers  en- 


ANATOMY.  47 

circle  single  compartments  only.  Each  of  these  two 
divisions  consists  of  an  outer  longitudinal  and  an  inner 
circular  layer,  and  at  the  point  where  the  outer  fibres 
join  two  adjacent  compartments  together  the  two  divi- 
sions of  the  muscular  coat  are  separated  by  loose  fibrous 
tissue  supporting  bloodvessels.  The  first  set  of  fibres 
would  tend  to  diminish  the  volume  of  the  entire  vesicle, 
while  the  action  of  the  second  set  must  be  confined  to 
the  single  compartment.  From  the  innermost  transverse 
layer  are  derived  the  fibres  which  form  the  numerous 
anastomosing  trabecular  that  beset  the  internal  surface 
of  the  vesicle. 

At  the  lower  end  of  the  vesicle  there  is  a  slight  in- 
crease in  the  thickness  of  the  muscular  wall,  but  the 
separation  of  layers,  as  in  the  ampulla,  is  imperfect,  and 
many  longitudinal  and  oblique  fibres  are  intermingled  in 
the  transverse  coat. 

The  epithelial  cells  of  the  mucosa  of  the  vesicle  are 
very  similar  to  those  of  the  ampulla.  They  are  usually 
lower  than  the  cells  found  in  corresponding  situations  in 
the  ampulla.  Lining  the  most  exposed  portions  of  the 
trabecule  they  are  reduced  to  a  cuboidal  shape,  and  the 
cells  of  the  second  row  become  infrequent.  In  the  re- 
cesses, and  in  the  small  diverticula  sometimes  described 
as  tubular  glands,  they  increase  in  height,  and  the  mucus- 
and  pigment-globules  are  more  abundant.  Except  at 
the  exposed  portion  of  the  summit  of  the  vesicle,  the 
secretory  function  of  the  epithelial  cell  is  evident  from 
the  character  of  the  protoplasm  and  from  the  presence 
of  mucus- vacuoles. 

The  ejaculatory  duct  as  it  passes  through  the  pros- 
tate gland  is  surrounded  by  a  thick  fibrous  wall  from 
which  rise  many  low  ridges  and  short  trabecular  that 
project  into  the  lumen  of  the  canal.     In  the  periphery  of 


48  MALE  SEXUAL  ORGANS. 

the  fibrous  coat  are  many  small  longitudinal  muscle- 
bundles  and  single  fibres,  and  also  a  number  of  cavern- 
ous blood-spaces  which  furnish  a  moderate  erectile  power 
to  this  portion  of  the  seminal  canal. 

Fig.  17. 


Lower  half  of  the  ejaculatory  duct,  showing  the  folds  of  the  mucous 
membrane. 

The  epithelial  cells  lining  the  duct  are  similar  in  most 
respects  to  those  of  the  vesicle  and  ampulla.  On  account 
of  their  height,  the  character  of  their  protoplasm,  and 
the  presence  of  mucus  and  pigment,  they  cannot  be  re- 
garded as  simple  pavement-epithelium.  Even  on  the 
exposed  rugae  they  retain  a  considerable  height,  while  in 
the  recesses  they  can  with  difficulty  be  distinguished 
from  the  cells  of  the  middle  portion  of  the  vesicle. 


CHAPTER    II. 


PHYSIOLOG-Y. 


As  a  preliminary  step  in  the  study  of  the  physiology 
of  the  organs,  the  anatomy  of  which  has  jnst  been  con- 
sidered, it  is  necessary  to  see  clearly  what  their  func- 
tions are. 

These  functions,  grouped  under  three  headings,  are 
as  follows:  First,  to  aid  in  attracting  the  testicular 
secretion  to  the  seminal  vesicles ;  secondly,  to  store  it 
there  temporarily  and  to  provide  means  to  preserve  its 
vitality  during  that  period;  and,  thirdly,  to  expel  the 
seminal  fluid  as  occasion  may  require.  All  the  litera- 
ture which  has  heretofore  appeared  on  this  subject  has 
drawn  largely  on  theoretical  considerations  for  its  sup- 
port, and  it  is  admitted  that  such  to  an  extent  is  the 
case  in  this  chapter.  Still,  the  attempt  has  been  made 
to  supplant  theory  by  facts  in  every  possible  instance, 
the  result  being  an  overthrow  of  many  old  ideas. 

In  connection  with  the  first  function,  namely,  that  of 
attracting  the  testicular  secretion  to  the  seminal  vesicle, 
the  opinion  is  here  held  that  that  duty  is  assigned  in 
great  measure  to  the  lower  enlarged  portion  of  the  vas 
deferens.  It  is  further  held  that  the  ampulla  of  Henle, 
the  enlarged  cavity  of  the  vas  deferens,  is  not  a  store- 
house for  seminal  fluid  in  common  with  the  cavity  of 
the  seminal  vesicle,  and  also  that  this  portion  of  the  vas 
deferens  is  not  in  the  least  associated  with  the  seminal 
vesicle  in  the  accomplishment  of  the  ejaculatory  act ; 
in  fact,  that  it  has  no  direct  connection  with  ejaculation. 

4 


50  MALE  SEXUAL  ORGANS. 

The  function  here  ascribed  to  the  lower  portion  of  the 
vas  deferens,  of,  as  it  were,  pumping  the  testicular  secre- 
tion into  the  vesicle,  has  never  apparently  been  mentioned 
before,  the  accepted  theory  having  been  that  this  struc- 
ture and  the  vesicle  shared  in  common  the  functions  of 
storing  and  expelling  the  seminal  fluid.    This  old  theory 
was  probably  due  to  the  idea,  mistaken  as  the  illustra- 
tions show,  that  the  cavities  in  connection  with  these 
two  organs  went  to  make  up  one  common  space,  thus 
furnishing  to  both  direct  connection  with  the  ejaculatory 
ducts.     Such,  however,  is  by  no  means  the  case.     The 
narrow  cavity  of  the  vas  deferens  communicates  at  a 
sharp  angle  with  that  of  the  seminal  vesicle  through  a 
sphincter  or,  perhaps  better,  a  valve-like  opening,  which 
when  stretched  is  not  half  the  diameter  of  the  ampulla 
of  Henle.     When  this  sphincter  or  valve  is  closed  the 
smaller  cavity  is  wholly  cut  off  from  the  larger.    As  the 
sphincter  of  this  opening  is  incorporated  in  the  wall  of 
the  seminal  vesicle,  it  is  evident  when  that  wall  is  in  a 
state  of  contraction,  as  would  occur  during  an  act  of 
ejaculation,  that  the  opening  would  be  closed,  thus  ren- 
dering it  impossible  for  the  two  cavities  to  empty  them- 
selves  in   unison  through  the  ejaculatory  duct.      The 
valvular  quality  also  of  the  opening  prevents  a  back 
flow  into  the  ampulla  when  the  vas  deferens  is  in  a  state 
of  relaxation.      Then,  besides,  the  ampulla  of  Henle, 
even  if  there  were  no  sphincter  or  valve,  is  too  small  a 
cavity  in  comparison  with  that  of  the  vesicle  to  cut  a 
figure  as  a  storehouse  for  semen.     If  this  structure  is 
not  directly  concerned  in  the  ejaculatory  act,  what  is 
then  its  function  ?    In  this  connection,  also,  it  is  well  to 
ask  the  important  question,  which  has  been  largely  over- 
looked in  the  consideration  of  this  subject,  How  does  the 
testicular  secretion  o-et  into  the  cavity  of  the  vesicle? 


PHYSIOLOGY.  51 

It  has  always  been  taught  that  this  was  accomplished 
wholly  by  the  movements  of  the  ciliated  epithelium. 
These  movements  may  aid  in  this  transportation.  The 
whole  canal  of  the  vas  deferens,  however,  is  not  lined 
with  ciliated  epithelium,  as  will  be  seen  certainly  in  ex- 
amining the  epithelium  lining  the  ampulla  of  Henle, 
which,  as  Dr.  Ewing  has  shown,  is  columnar  in  char- 
acter. There  must,  therefore,  be  some  other  force  to  aid 
in  this  now  of  secretion  from  the  testicle.  This  other 
force  lies  in  the  muscular-clubbed  end  of  the  vas  defer- 
ens. In  considering  the  anatomy  of  this  part  attention 
has  been  called  to  the  thickness  of  these  walls  as  seen 
on  section,  and  to  the  muscular  trabecular  which  line  the 
interior  of  the  ampulla  of  Henle.  Suppose  now  these 
muscular  walls  contract — and  they  do  contract  at  times, 
for  what  other  function  has  muscular  fibre? — the  contents 
of  the  ampulla  would  be  thrown  out  into  the  cavity  of 
the  vesicle.  If  then  the  little  opening  between  these 
two  cavities,  exercising  its  sphincter-like  or  valvular 
qualities,  should  close  a  back  flow  would  be  prevented. 
The  muscular  walls  then  becoming  flabby  and  relaxed, 
a  tendency  to  a  vacuum  would  exist  in  the  ampulla  of 
Henle  exactly  as  exists  under  like  circumstances  in  the 
auricle  of  the  heart,  which  tendency  would  exert  a  gentle 
suction  or  traction  on  the  fluid  in  the  distal  portion  of 
the  canal,  thus  gradually  attracting  it  into  the  cavity  of 
Henle.  When  this  cavity  refills  another  contraction 
would  ensue,  emptying  it  again  according  to  the  general 
rule  which  applies  to  all  muscular  cavities  when  dis- 
tended. 

We  now  come  to  the  consideration  of  the  second  func- 
tion of  these  organs,  namely,  to  store  temporarily  the 
testicular  secretion  and  to  provide  means  to  preserve  its 
vitality  during  that  period.     It  has  already  been  shown 


52  MALE  SEXUAL  ORGANS. 

that  the  cavity  of  the  vas  deferens  is  not  a  storehouse 
for  seminal  fluid,  hence  this  function  devolves  entirely 
upon  the  seminal  vesicle.  The  means  provided  to  nourish 
and  preserve  the  testicular  fluid  during  its  confinement 
in  the  seminal  vesicle  is  supplied  by  the  secretion  of  the 
vesicle  itself.  The  epithelium  lining  the  vesicle,  and 
especially  that  lining  the  canals  which  empty  into  the 
main  cavity  or  pelvis  of  the  vesicle,  have  secreting  quali- 
ties and  furnish  this  vesicular  fluid.  It  is  to  this  fluid 
that  semen  owes  its  gross  appearances  and  character- 
istics. In  fact,  without  the  aid  of  the  microscope,  it  is 
impossible  to  say  whether  a  given  specimen  of  ejacu- 
lated fluid  is  true  semen,  or  whether  it  is  made  up  sim- 
ply of  vesicular  secretion,  together  with,  as  exists  in  all 
instances,  a  certain  amount  of  prostatic  secretion,  which 
last  plays  the  part  apparently  of  a  lubricant.  In  prac- 
tice it  is  frequent  to  see  such  ejaculated  fluid  which  is 
minus  the  testicular  secretion  in  the  cases  of  men  sterile, 
but  perfectly  potent,  who  have  had  an  epididymitis  in 
connection  with  both  sides,  which  has  rendered  both 
efferent  ducts  impervious.  The  normal  vesicular  con- 
tents are  white  with  a  slightly  bluish  tinge ;  in  fact,  it  has 
much  the  color  of  skimmed  milk,  although  somewhat 
denser  in  consistency.  On  exposure  to  the  air  this  fluid 
becomes  quite  viscid  and  sticky,  characteristics  which 
are  present  only  to  a  very  slight  degree  when  it  is 
freshly  ejaculated.  It  is  distinctly  alkaline  in  reaction, 
a  property  of  vital  importance,  as  spermatozoa  die  im- 
mediately in  an  acid  media.  It  has  a  peculiar  heavy 
odor,  and  coagulates  somewhat  on  heating.  It  is  saline, 
and  on  standing,  probably  due  to  the  lowering  of  its 
natural  temperature,  numerous  groups  of  crystals  ap- 
pear. These  are  called  Bottcher's  crystals  (Virchow's 
Archiv,  1865,  Bd.  ii.  p.  525),  after  the  author  who  first 


PHYSIOLOGY.  53 

described  them.  Their  chemical  composition  has  not 
been  definitely  determined,  bnt  it  seems  to  consist  of 
phosphates.  Under  the  microscope  the  fluid  element 
appears  transparent  and  slightly  refractive,  with  here 
and  there  an  irregular  striation  marking  little  areas 
where  the  fluid  is  more  viscid  than  elsewhere.  In  fact, 
the  picture  presented  is  much  that  of  ordinary  mucus. 
Besides  the  spermatozoa,  a  description  of  which  here  is 
not  necessary,  the  fluid  is  seen  to  contain  a  few  leuco- 
cytes, numerous  epithelial  cells  slightly  larger  than  leu- 
cocytes, a  few  round  refractive  cells,  the  largest  of  which 
are  about  the  size  of  those  from  the  vesical  neck,  and 
considerable  granular  material,  which  is  usually  grouped 
rather  irregularly.  The  various  gross  and  microscopical 
appearances  of  the  semen  as  presented  in  pathological 
conditions  will  be  mentioned  later  on. 

In  studying  the  anatomy  it  has  been  seen  that  those 
canals  which  secrete  the  vesicular  fluid  enter  the  cavity 
of  the  vesicle,  as  a  rule,  at  a  very  sharp  angle.  In  fact, 
in  the  case  of  the  two  chief  canals  in  Fig.  7,  the  angle 
is  so  acute  that  a  fluid  passing  along  them  would  be 
taking  a  course  almost  entirely  opposite  to  that  which  it 
would  later  on  have  to  take  in  passing  from  the  main 
cavity  of  the  vesicle  to  the  ejaculatory  duct.  The 
reason  for  this  is  obvious  ;  it  is  to  protect  these  secret- 
ing canals,  and  to  prevent  their  contents  from  being 
emptied  out  during  the  act  of  ejaculation.  By  this  pro- 
vision of  nature  the  seminal  vesicle  cannot  be  squeezed 
dry  by  direct  muscular  action,  as  might  be  the  case  were 
it  a  pear-shaped  cavity  with  smooth  lining  walls,  but  at 
the  end  of  the  ejaculatory  act  the  canals  continue  quite 
full.  Then,  after  the  muscular  contraction,  the  walls  of 
the  cavity  of  the  vesicle  becoming  flabby,  the  suction 
principle,  which  we  have  already  observed  in  studying 


54  MALE  SEXUAL   ORGANS. 

the  action  of  the  clubbed  end  of  the  vas  deferens,  comes 
into  play,  causing  the  fluid  in  the  canals  promptly  to 
flow  into  the  main  cavity  of  the  vesicle,  where  it  remains 
ready  to  act  as  a  medium  to  preserve  the  spermatozoa, 
which  are  rhythmically  ejected  from  the  ampulla  of  Henle. 
A  knowledge  of  this  physiological  point  explains  the 
reason  why  during  a  second  act  of  sexual  intercourse 
shortly  following  a  first  act  almost  as  much  semen  is 
oftentimes  ejaculated  as  during  the  first  act,  while  as  a 
result  of  further  shortly  succeeding  acts  almost  no  fluid 
is  ejaculated,  and  that  which  is  thrown  off  probably 
consists  largely  of  prostatic  secretion. 

The  Third  Function,  that  of  Expelling1  the  Seminal  Fluid 
as  Occasion  may  Require.  This  consists  of  a  strong 
simultaneous  contraction  in  connection  with  the  muscu- 
lar fibres  of  the  prostate  and  of  the  walls  of  each  seminal 
vesicle.  In  Fig.  7  we  have  seen  the  firm  muscular 
structure  which  goes  to  make  up  the  walls  of  the  main 
cavity  of  the  vesicle,  together  with  the  trabecular  which 
appear  on  its  inner  surface,  and  which  closely  resemble 
those  in  connection  with  the  cardiac  ventricles.  In  Fig. 
7,  and  in  Figs.  2  and  3  and  Plate  VI.,  attention  has 
already  been  drawn  to  the  fact  that  the  muscular  fibres 
of  the  prostate  so  blend  with  those  of  the  vesicular  wall 
that  it  is  difficult  to  tell  the  exact  limits  of  the  two 
organs.  In  Plates  II.  and  III.  the  strong-  fibrous  bands 
which  radiate  backward  and  downward  from  the  sides  of 
the  prostate  and  over  the  vesicles  have  been  pointed  out, 
and  it  has  also  been  shown  that  a  contraction  of  the 
prostatic  body  would  tighten  those  fibres  which  are 
blended  posteriorly  with  the  fibrous  sheath  of  the  rec- 
tum, thus  tending  to  elongate  the  sheaths  of  the  vesi- 
cles, which  last  are  closely  adherent  to  these  radiating 
bands,  and  consequently  to  squeeze,  as  it  were,  these 


PHYSIOLOGY.  55 

oro-ans.  If  now  a  o-eneral  contraction  of  the  muscular 
fibres  in  connection  with  the  prostate  and  vesicles  takes 
place,  and  there  is  no  reason  to  suppose  that  a  partial 
contraction  occurs,  what  happens  ?  Two  things  simul- 
taneously :  the  contents  of  the  main  cavity  of  the  vesi- 
cles are  expelled  along  and  out  of  the  ejaculatory  ducts 
with  considerable  force,  and  the  neck  of  the  bladder  back 
of  the  region  of  the  opening  of  the  ejaculatory  ducts  is 
firmly  closed,  rendering  a  backward  flow  of  the  semen 
into  the  bladder-cavity  impossible.  This  latter  condi- 
tion is  accomplished  by  reason  of  the  circular  arrange- 
ment of  the  muscular  fibres  of  the  prostate  about  the 
vesical  neck.  The  muscular  structures  in  connection 
with  the  membranous  urethra  do  not  aid  ejaculation. 
In  fact,  rather  than  aiding  the  act,  they  in  a  passive  way 
offer  some  resistance  to  it.  This  is  shown  by  the  cases 
of  certain  individuals  in  whom  the  prostatic  vesical  neck 
has  been  extensively  injured,  associated  generally  with 
loss  of  gland-substance  as  a  result  of  operative  proce- 
dures. Under  those  conditions  the  semen  on  being 
forced  into  the  urethra  may  meet  with  more  resistance 
from  the  membranous  than  from  the  prostatic  urethra, 
and  consequently  may  be  thrown  into  the  bladder  rather 
than  out  of  the  meatus. 

It  is  thus  seen  that  the  forces  which  transmit  the 
testicular  secretion  from  its  source  to  its  point  of  elimi- 
nation are  really  analogous  to  those  which  govern  the 
circulation  of  the  blood.  The  clubbed  end  of  the  vas 
deferens  corresponds  to  the  auricle  and  the  seminal  vesi- 
cle associated  with  the  prostate  to  the  ventricle.  The 
sphincter  or  valve-like  opening  between  the  ampulla  of 
Henle  and  the  cavity  of  the  vesicle  plays  the  part  of  the 
mitral  or  tricuspid  valve.  Although  the  principles  of 
the  machinery  of  the  sexual  apparatus  and  the  heart  are 


56  MALE  SEXUAL  ORGANS. 

the  same,  there  are  differences  in  the  applications  of  those 
principles.  In  the  first  place,  each  contraction  of  the 
auricle  is  followed  by  a  corresponding  contraction  of  its 
ventricle,  and  the  capacity  of  the  auricle  corresponds  to 
that  of  its  ventricle.  With  the  sexual  apparatus,  how- 
ever, the  contraction  of  the  clubbed  end  of  the  vas  def- 
erens bears  no  direct  connection  with  the  contraction  of 
the  vesicle  and  the  prostate,  and  the  capacity  of  the  am- 
pulla of  Henle  is  very  much  less  than  that  of  the  cavity 
of  the  vesicle.  In  fact,  the  contractions  of  the  clubbed 
end  of  the  vas  deferens  are  very  frequent  in  comparison 
with  those  of  the  larger  cavity,  and  are  in  the  nature  of 
a  constant  slow  pumping  into  the  larger  cavity  of  the 
testicular  secretion  as  it  collects  in  the  smaller  cavity. 
The  function  of  the  ventricle,  also,  is  purely  and  simply 
that  of  a  pump,  while  added  to  this  the  vesicle  serves  in 
the  capacity  of  a  storehouse  and  a  commissary.  While 
the  nerve-supply  to  the  ventricle  corresponds  to  that  to 
the  auricle,  and  is  involuntary  in  character,  the  supply 
to  the  vesicle  and  prostate  is  not  wholly  involuntary,  and 
does  not,  therefore,  entirely  correspond  to  that  to  the 
vas  deferens.  The  so-called  sexual  nerve-centre,  which 
is  in  the  lumbar  portion  of  the  spinal  cord,  has  the  chief 
control  of  ejaculation.  The  question,  however,  of  nerve 
action  and  supply  to  these  parts  will  not  be  further  con- 
sidered here,  not  only  because  numerous  neurologists 
have  already  written  ably  on  the  subject,  but  also  be- 
cause such  investigators  are  the  ones  best  equipped  for 
this  consideration. 

The  amount  of  testicular  and  vesicular  fluid  secreted 
in  a  given  time  varies  greatly,  and  depends  much  on  the 
mode  of  life  and  the  conditions  of  the  individual.  A 
person  who  is  a  high-liver,  who  takes  a  fair  amount  of 
physical  exercise,  but  not  enough  to  cause  fatigue,  who 


PHYSIOLOGY.  57 

has  no  mental  worry  or  strain,  and  who  allows  his  mind 
to  dwell  on  women,  is  under  conditions  which  seem  to 
make  him  most  potent  sexually,  and  which  cause  the 
seminal  secretions  to  be  most  active.  Oftentimes  with 
an  individual  who  lives  thus  the  mind  reverts  to  women, 
especially  in  the  form  of  erotic  dreams,  even  though 
there  be  a  mental  attempt  to  avoid  such  thoughts.  If, 
on  the  contrary,  a  person  is  poorly  fed  and  overworked 
mentally  and  physically,  the  thought  of  a  woman  may 
be  even  repugnant  to  him,  and  should  he  attempt  the 
sexual  act  he  will  find  it  fatiguing  and  associated  with 
a  moderate-sized  seminal  discharge. 

The  amount  of  fluid  ejaculated  at  a  given  instance 
varies  much,  depending  in  a  measure,  as  has  been  seen, 
on  the  frequency  of  the  act.  When  the  act  is  solitary 
and  infrequent  the  usual  volume  of  the  fluid  is  from 
half  a  drachm  to  a  drachm.  Robin  (Article  Sperme  du, 
Diet.  Encycloijedique,  3d  Serie,  t.  xi.,  1882)  has  estimated 
the  quantity  at  from  0.75  c.c.  to  7  c.c.  The  quantity 
apparently  varies  considerably  with  the  individual. 


CHAPTER    III. 


PATHOLOG-Y 


The  scope  of  this  chapter  will  be  confined  to  the 
consideration  of  morbid  conditions  which  directly  affect 
the  male  sexual  function,  giving  rise  to  derangements, 
a  clinical  study  of  which  will  be  undertaken  further 
on.  By  so  doing  much  of  the  pathology  of  the  pros- 
tate will  be  eliminated,  as  most  affections  of  that 
organ,  especially  senile  changes,  do  not,  certainly  in 
any  marked  degree,  affect  the  sexual  function,  but 
cause  disturbances  rather  in  connection  with  urinary 
drainage.  That  the  sexual  function  is  so  little  affected 
by  most  morbid  changes  in  the  prostate  is  probably  be- 
cause its  power  of  muscular  contraction  is  rarely  lost. 
It  is  in  connection  with  the  seminal  vesicles  themselves, 
including  their  contents,  their  walls,  the  perivesicular 
tissues,  and  the  ejaculatory  ducts,  that  most  of  the  path- 
ological changes  occur  which  cause  disturbances  in  the 
sexual  function,  and  the  amount  of  disturbance  in  this 
function  which  these  pathological  processes  cause  seems 
to  depend  largely  at  least  on  the  extent  to  which  they 
interfere  with  the  act  of  ejaculation.  The  changes  due 
to  inflammation  are  the  chief  pathological  factors  in  this 
consideration.  As  a  result  of  them  the  contents  of  the 
vesicles  may  lose  in  great  measure  their  liquid  qualities, 
becoming  thickened  and  gelatinous,  the  walls  of  the 
ejaculatory  ducts  may  grow  inelastic  and  •  unyielding, 
the  walls  of  the  main  cavity  of  the  vesicle  may  become 
dense  and  rigid,  and  associated  with  this  condition  the 
perivesicular  connective  tissue  may  in  the  case  of  ex- 


PATHOLOGY.  59 

treme  inflammation  become  extensively  infiltrated ;  or 
instead  of  thickening  and  rigidity  of  the  vesicular  walls 
inflammatory  changes  may,  by  reason  of  ulceration,  cause 
loss  of  substance  and  consequent  thinning  of  those 
structures.  Besides  inflammatory  factors,  the  sexual 
function  may  be  impaired  by  motor  or  trophic  disturb- 
ances in  connection  with  the  nerve-supply  to  the  parts, 
by  traumatisms,  new  growths,  and  calculi. 

Inflammations  can  be  grouped  under  the  headings 
simple,  gonorrhoea!,  and  tubercular.  There  may  be, 
also,  a  syphilitic  inflammation ;  but  if  so,  it  has  not  as 
yet  been  demonstrated.  Out  of  twenty-two  cases  of 
inflammation  of  the  vesicles  investigated  by  the  author, 
apparently  seven  were  tubercular,  fourteen  were  either 
directly  or  indirectly  due  to  gonorrhoea,  and  one  was 
simple  in  character. 

Simple  inflammation  involving  the  seminal  vesicles  is, 
as  is  seen,  rare  in  comparison  with  the  other  two  forms. 
It  is  usually,  though  not  necessarily,  of  a  light  grade. 
Its  chief  causes  are  sexual  excesses  practised  for  a  long- 
period,  and  in  most  instances  having  their  commence- 
ment at  an  early  age,  as  from  twelve  to  fourteen  years, 
masturbation,  unnatural  sexual  relations,  such  as  with- 
drawing prematurely,  the  use  of  tight  condoms,  etc., 
occasionally  total  abstinence  from  sexual  pleasures  dur- 
ing the  active  period  of  adult  life,  and  sometimes  gene- 
ral nervous  debility,  as  may  exist  in  cases  where  there 
are  cardiac,  pulmonary,  or  renal  disturbances  and  the 
like.  Although  these  are  the  initial  causes  in  most 
instances,  still  it  is  often  found  that  the  primary  in- 
flammation has  been  much  intensified  by  the  surgical 
procedures,  such  as  caustics  to  the  deep  urethra,  over- 
distention  by  sounds  etc.,  which  have  been  resorted  to 
for  the  relief  of  symptoms. 


60  MALE  SEXUAL  ORGANS. 

Inflammations  resulting  from  gonorrhoea  can  best  be 
subdivided  into  direct  and  indirect.  Direct  gonorrhoeal 
inflammations  occur  when  the  disease,  in  its  acute  stage, 
extends  directly  from  the  urethra  along  the  ejaculatory 
duct  and  into  the  vesicle.  Such  inflammations  are  very 
acute  and  severe.  The  contents  of  the  vesicle  become 
purulent.  The  walls  of  the  sac  are  always  involved,  as 
well  as  in  most  instances  the  perivesicular  tissues,  and 
occasionally  in  the  severest  cases  the  perivesicular  in- 
flammation extends  sufficiently  to  involve  the  perito- 
neum, setting  up  a  localized  peritonitis  which  in  a  few 
recorded  cases  has  secondarily  become  general.  These 
direct  acute  cases  are  infrequent  as  compared  with  the 
indirect  and  more  chronic  ones.  Indirect  gonorrhoeal 
inflammations  result  from  an  extension  to  the  vesicle  of 
inflammations  connected  with  urethral  lesions  the  source 
of  which  was  a  gonorrhoea,  In  many  such  instances  the 
gonorrhoeal  attack  antedates  the  vesiculitis  by  many 
years.  This  form  of  inflammation  is  usually  chronic. 
The  vesicular  contents  are  more  or  less  purulent,  stringy, 
and  viscid,  and  in  the  severer  cases  the  perivesicular 
tissues  as  well  as  those  constituting  the  ducts  and  the 
vesicular  walls  are  involved.  Occasionally  the  gono- 
coccus  persists  in  such  instances.  This  form  of  inflam- 
mation resembles  the  simple  variety.  It  differs,  how- 
ever, in  that  it  is  as  a  rule  more  chronic  and  its  lesions 
more  severe.  E.  Finger  (Interned.  Min.  Runelsehetu, 
"Wien,  Feb.  12,  1893)  has  called  attention  to  and  laid 
much  stress  on  this  indirect  form  of  gonorrhoeal  inflam- 
mation. 

Tubercular  inflammation  in  this  connection  is  com- 
mon and  very  important.  It  may  be  acute,  subacute,  or 
chronic,  the  last  being  its  usual  form.  The  acute  form 
is  rare  and  is  associated  with  an  active  congestion  and 


PATHOLOGY.  61 

ulceration  of  the  mucous  membrane  of  the  vesicle,  to- 
gether with  much  purulent  distention  of  the  sac.  The 
subacute  variety  is  met  with  much  oftener  than  the 
acute.  It  is  of  a  light  grade,  and  gives  rise  to  but  few 
subjective  symptoms,  and  those  of  a  temporary  char- 
acter, appearing  generally  as  a  result  of  sexual,  alcoholic, 
or  physical  excesses.  It  causes  a  slight  thickening  of 
the  vesicular  walls  and  changes  in  the  consistency  of  the 
seminal  fluid,  as  will  be  described  further  on.  This 
form  may  end  in  resolution,  or  it  may  be  a  forerunner  of 
the  chronic  variety.  The  chronic  form  is  much  the 
commonest.  In  this  form,  although  the  vesicular  fluid 
and  the  walls  of  the  sac  are  affected,  the  latter  becoming 
thickened  and  inelastic,  still  the  characteristic  feature  is 
the  extensive  involvement  of  the  perivesicular  tissues, 
which  in  the  early  stages  are  invaded  by  a  hard  oedema. 
Later  on,  connective-tissue  proliferation  with  occasion- 
ally purulent  foci  takes  the  place  of  the  oedema.  It  is 
a  very  common  occurrence  with  strumous  individuals  for 
a  chronic  tubercular  inflammation  to  graft  itself  upon 
an  indirect  gonorrhoeal  one  in  connection  with  these 
parts.  Several  writers,  Guyon  in  particular,  have  called 
attention  to  this  point,  which  holds  good  not  only  with 
reference  to  the  seminal  vesicles,  but  also  as  regards  the 
neck  of  the  bladder.  Tubercular  processes  in  most  in- 
stances extend  from  the  deep  urethra  to  the  seminal  vesi- 
cle, and  in  some  cases  seem  to  originate  in  the  seminal 
vesicle  itself. 

The  theory,  formerly  quite  prevalent,  that  the  epididy- 
mis is  the  frequent  seat  of  primary  tubercular  deposits, 
from  which  source  the  vesicle  is  secondarily  attacked,  is 
confuted  by  clinical  stud}^  and  is  fast  being  abandoned. 

The  author  has  observed  a  goodly  number  of  cases  in 
which  at  an  early  examination  he  has  been  able  to  detect 


62  MALE  SEXUAL  ORGANS. 

tubercular  disease  in  a  vesicle  where  some  time  after- 
ward the  corresponding  epididymis  became  infiltrated 
with  a  tubercular  deposit.  In  most  such  instances  there 
would  be  nothing  in  the  feel  to  indicate  an  involvement 
of  the  cord.  It  is  in  cases  of  this  nature  that  a  careless 
observer  might  advocate  castration  with  the  object  of 
eradicating  the  entire  focus  of  disease. 

It  is  more  common  for  any  kind  of  an  inflammatory 
process,  in  a  given  instance,  to  attack  both  vesicles  with 
varying  degrees  of  intensity  rather  than  equally.  In 
fact,  it  is  not  unusual  for  one  vesicle  wholly  to  escape, 
remaining  perfectly  normal,  while  the  other  may  be 
extensively  involved.  This  is  what  is  to  be  expected, 
since  the  two  organs  are  wholly  distinct. 

The  extension  of  an  inflammatory  process  from  the 
seminal  vesicle  to  the  ampulla  of  Henle,  and  along  the 
vas  deferens  to  the  epididymis,  occurs,  as  everyone 
knows ;  but  in  what  percentage  of  cases,  and  just  what 
agencies  determine  this  extension,  are  questions  which 
have  not  been  settled.  The  degree  of  inflammation  in 
connection  with  the  vesicle  certainly  does  not  determine 
it,  as  a  most  severe  inflammation  of  that  organ  may  show 
no  tendency  to  extend  in  this  manner,  while  an  inflam- 
mation verv  slio'ht  and  transient  as  regards  the  vesicle 
may  show  itself  severe  and  persistent  in  connection  with 
the  epididymis  or  cord  or  both  these  structures.  Un- 
fortunately, little  is  known  as  to  the  effect  of  inflamma- 
tory processes  on  the  clubbed  end  of  the  vas  deferens. 
Perhaps,  as  the  result  of  very  severe  inflammations,  its 
function  may  be  destroyed,  and  the  cavity  of  the  ampulla 
of  Henle  may  be  shut  off  from  the  cavity  of  the  vesicle. 
There  have,  however,  as  yet  been  no  clinical  symptoms 
which  could  be  differentiated  as  due  to  a  derangement  in 
this  part.     Pathological  conditions,  also,  in  connection 


PATHOLOGY.  63 

with  the  epididymis  and  cord,  although  of  great  impor- 
tance, especially  in  considerations  of  sterility,  rarely  give 
rise  to  symptoms  directly  affecting  the  sexual  function, 
and  consequently  will  not  be  further  considered  in  this 
connection.  (The  writer  is  aware  that  this  last  state- 
ment is  at  variance  with  many  of  the  teachings  of  the 
present  time,  which  lay  great  stress  on  the  condition  of 
the  testicle  and  cord  in  sexual  disturbances,  utterly 
ignoring,  usually  through  ignorance,  the  condition  of 
the  seminal  vesicles  in  these  instances.) 

An  element  of  great  clinical  as  well  as  pathological 
importance  in  connection  apparently  with  any  of  the 
forms  of  vesicular  inflammation  is  that  of  germ  infec- 
tion.  Such  infection  in  most  if  not  all  cases  occurs 
secondarily  to  the  primary  inflammatory  factor,  and  acts 
to  intensify  and  to  complicate  it.  That  such  an  infec- 
tion is  secondary  is  based  not  only  on  clinical  experi- 
ence, but  also  and  more  especially  on  the  laws  which 
govern  germ  infection  and  proliferation,  as  set  forth  by 
the  experiments  and  investigations  of  Guy  on  and  Albar- 
ran,  and  later  by  others,  chiefly  of  the  decker  school,  in 
connection,  to  be  sure,  with  the  bladder ;  but  it  is  reason- 
able to  suppose  that  the  laws  of  germ  infection  and 
proliferation  which  govern  the  bladder  govern  also  the 
seminal  vesicle  or  any  other  like  muscular  sac,  as,  for 
instance,  the  gall-bladder  or  the  kidney  pelvis.  The 
function  of  the  seminal  vesicle  is  allied  to  that  of  the 
bladder  in  that  it  is  a  muscular  sac  lined  with  mucous 
membrane,  which  periodically  empties  itself  of  its  fluid 
contents.  These  French  investigators  have  found  that 
germs  of  various  kinds  when  injected  into  a  healthy 
bladder  fail  to  take  root  and  are  soon  eliminated.  They 
have  further  found  that,  in  order  to  insure  a  colonization 
of  the  germs  when  introduced,  one  of  two  factors,  and 


64  MALE  SEXUAL  ORGANS. 

oftentimes  a  combination  of  the  two,  is  essential.  These 
two  factors  are  inflammation  in  connection  with  the 
vesical  mucous  membrane  and  stagnation  of  urine  such 
as  would  occur  artificially  were  a  ligature  placed  about 
the  penis,  or  naturally  in  case  of  stricture,  prostatic  ob- 
struction, vesical  atony,  paralysis,  etc.  As  just  such 
conditions  oftentimes  exist  in  seminal  vesiculitis,  it  is 
but  natural  to  suppose  that  they  govern  germ  prolifera- 
tion here  as  well  as  with  the  bladder.  That  germ  infec- 
tion in  connection  with  the  vesicles  occurs  will  be 
demonstrated  in  a  chapter  further  on.  Such  germ  in- 
fection is  doubtless  in  most  instances  introduced  from 
the  urethra  and  along  the  ejaculatory  duct ;  still,  some- 
times its  source  is  probably  through  the  intervening 
tissues  and  the  vesicular  Avails  from  some  near-by  focus 
of  germ-growth.  The  rectum  presents  a  constant  near- 
by focus,  and  as  E.  Reymond  (Annal  des  Malad.  des 
Organ.  Genito.-  Urinaires,  Paris,  April  and  May,  1893) 
has  conclusively  demonstrated  that  germs  can  penetrate 
the  bladder-wall  and  the  intervening*  tissues  from  neigh- 
boring-  foci  when  that  organ  remains  inflamed  and  dis- 
tended,  the  same  is  in  all  probability  true  under  like 
conditions  with  reference  to  the  seminal  vesicle. 

Regarding  motor  and  trophic  nerve-disturbances  in 
connection  with  the  parts  under  consideration  little  can 
be  said.  It  is  not  known  that  any  pathological  condi- 
tions result  from  a  tonicity  of  the  motor  nerves.  There 
are,  however,  pathological  conditions  which  result  from 
an  impairment  in  this  nerve-force.  In  such  instances, 
owing  to  imperfect  expulsive  action,  the  contents  of  the 
vesicles  become  thickened  and  gelatinous.  The  vesicles 
get,  as  it  were,  into  a  state  of  constipation,  and  the  same 
secondary  changes  result  from  this  state  in  connection 
with  the  vesicle  as  with  the  bowel.     The  thicker  and 


PATHOLOGY.  Qo 

more  gelatinous  the  contents  of  the  vesicles  become  from 
the  impairment  in  the  expulsive  force,  the  harder  it  is  to 
empty  them.  The  result  is  that  they  become  over- 
distended.  Finally,  this  over-distention  is  liable  to  set 
up  an  inflammation  in  connection  with  the  walls  of  the 
sac,  and  this  condition  of  affairs  exposes  the  sac  to  germ 
infection.  Thus  it  can  be  seen  that  a  condition  which 
at  its  commencement  is  of  little  moment  may  lead  to 
aggravated  vesicular  disease.  All  that  there  is  to  be 
said  regarding  trophic  nerve-disturbances  is  based  on 
the  condition  existing  in  Fig.  5.  Here  a  marked 
atrophy  was  found  to  exist  in  connection  with  the  right 
seminal  vesicle  and  the  clubbed  end  of  its  vas  deferens, 
and  as  the  cavity  of  the  vesicle  was  empty  it  was  evi- 
dent that  this  atrophy  involved  not  only  the  muscular 
structures  but  also  the  secreting  epithelia.  The  pros- 
tatic body,  however,  in  this  instance  was  not  appreciably 
diminished  in  any  portion,  nor  was  there  any  change  in 
the  size  or  consistency  of  the  corresponding  testicle  on 
comparing  it  with  the  left  one,  both  these  organs  appear- 
ing normal  to  the  feel.  Unfortunately  no  clinical  his- 
tory accompanied  this  dissection.  It  is  probable  that 
the  atrophic  changes  in  this  instance  are  analogous  to 
those  which  occasionally  involve  the  testicle. 

"Whether  atrophy  of  the  testicle  can  be  occasioned  by 
an  inflammatory  condition  of  the  corresponding  seminal 
vesicle  is  not  known.  The  author  has,  however,  ob- 
served in  two  instances  testicular  atrophy,  there  being 
a  chronic  inflammation  of  the  corresponding  seminal 
vesicle,  which  from  the  history  of  the  cases  seemed  to 
have  antedated  the  atrophy  of  the  testicles.  Both  of 
these  cases  have  been  cited  in  the  chapter  on  illustrative 
instances.  In  one  of  them  an  operation  for  varicocele 
had  also  preceded  the  atrophy,  so  that  in  that  instance 

5 


66  MALE  SEXUAL  ORGANS. 

the  operation  might  be  said  to  have  been  the  cause ;  but 
in  the  other  no  varicocele  existed,  and  no  operation  had 
been  performed.  In  fact,  there  was  apparently  nothing, 
unless  it  were  the  vesiculitis,  to  account  for  the  atrophy. 
In  neither  of  these  cases,  however,  was  there  any  appar- 
ent atrophy  of  the  prostate  as  a  whole  or  of  the  portion 
corresponding  to  the  atrophied  testicles.  There  was, 
also,  no  atrophy  of  the  walls  of  the  inflamed  vesicles. 
These  clinical  observations  are  opposed  to  the  theory 
that  loss  or  destruction  of  one  or  both  testicles  is  fol- 
lowed by  a  corresponding  withering  of  the  muscular 
substance  of  the  prostate  as  a  whole,  or  of  the  lateral 
portion  corresponding  to  the  testicle  which  has  been  re- 
moved or  destroyed. 

Traumatisms  in  connection  with  the  seminal  vesicles 
are  rare  owing  to  the  protected  position  of  the  parts. 
They  may  be  injured  by  a  perforating  wound  involving 
the  rectum  and  bladder,  such  as  occurs  occasionally  when 
one  is  thrown  against  or  sits  upon  a  sharp  body.  They 
are  also  occasionally  involved,  one  or  both  ejaculatory 
ducts  being  cut  across  or  lacerated  in  surgical  pro- 
cedures, as  in  vesical  puncture  per  rectum  for  the  relief 
of  retention,  in  extensive  prostatectomies,  in  median 
sections,  where  the  cut  is  very  deep,  and  in  attempts  to 
draw  a  stone  too  large  in  size  through  any  perineal  cut, 
be  it  median  or  lateral.  From  such  injuries  an  inflam- 
mation of  the  whole  vesicle  results,  which  oftentimes 
extends  to  the  epididymis. 

The  new  growths  which  have  been  observed  acting 
as  factors  in  disturbing  the  sexual  function  are  echino- 
coccus  cysts,  cancer,  and  very  rarely  sarcoma.  The 
recto- vesical  space  is  quite  a  favorite  starting-place  for 
cysts  of  this  nature,  probably  owing  to  its  dependent 
position.     In  Sajous'  Annual,  articles  on  "  Genito-Uri- 


PATHOLOGY.  67 

nary  Diseases,"  years  1893  and  1894,  numerous  refer- 
ences are  made  to  the  literature  relating  to  this  subject. 
It  is  only  occasionally  that  these  cysts  interfere  with 
the  sexual  function,  and  when  they  do,  it  is  by  so  grow- 
ing as  to  exert  a  pressure  on  the  vesicles. 

Cancer  and  sarcoma  produce  disturbances  by  involv- 
ing the  seminal  vesicles  or  the  prostate,  as  it  is  evident 
if  the  latter  body  is  implicated  to  any  extent  its  function 
of  contraction  is  destroyed.  Cancer  in  this  connection 
is  usually  primary  in  connection  with  the  prostate  or 
bladder,  involving  the  vesicle  secondarily.  Guelliot 
(JDes  Yesicules  SSminales,  Coccoz,  Paris,  1883)  has  col- 
lected fourteen  cases  of  cancer  involving  the  vesicles,  in 
only  one  of  which  was  the  growth  primary.  Thorndike 
(Morrow's  System,  vol.  i.,  "  Diseases  of  the  Seminal 
Vesicles,"  Appleton,  1893)  records  one  such  case  which 
occurred  in  the  service  of  Gay,  of  Boston.  Sarcoma  is 
very  rare.  Thorndike,  in  the  article  just  referred  to,  has 
been  able  to  find  the  records  of  but  two  such  cases,  one 
of  these,  Zahn's  (Deut.  Zeitsclirift  f.  Cliir.,  1885,  v.  22), 
being  primary  in  the  vesicle.  The  subject  of  growths 
in  this  connection,  therefore,  owing  to  their  rarity,  is 
not  of  much  practical  importance. 

Calculi  of  the  seminal  vesicles  are  rare.  Guelliot  in 
his  work,  reference  to  which  has  just  been  given,  care- 
fully reviews  all  the  literature  there  is  on  this  subject. 
This  author  asserts  that  these  bodies  are  usually  small 
and  bear  a  strong  resemblance  to  prostatic  calculi.  He 
records  an  analysis  of  one  of  them  made  by  Peschier, 
which  showed  the  mass  to  consist  of  phosphate  of  lime, 
86  parts ;  carbonate  of  lime,  2  parts,  and  animal  matter, 
12  parts.  Keyes,  of  Kew  York,  some  years  ago,  re- 
moved a  concretion  the  size  of  a  bean  from  what  appar- 
ently was  the  ejaculatory  duct  by  means  of  a  median 


68  MALE  SEXUAL  ORGANS. 

perineal  section.  Before  the  operation  the  concretion 
conld  be  felt  on  passing  a  sound,  the  body  apparently 
protruding  somewhat  beyond  the  opening  of  the  dnct. 
The  patient  suffered  severely  before  the  operation  from 
painful  ejaculations.  This  symptom  was  in  great  meas- 
ure relieved  by  the  removal  of  the  concretion.  The 
author  recently  met  in  his  own  practice  a  case  of  this 
description  which  will  be  recorded  later  on.  The  calcu- 
lus was  about  the  size  of  a  grape-seed  and  quite  rough. 
It  was  finally  discharged  along  the  ejaculatory  duct 
associated  with  a  large  blood-clot  during  an  involuntary 
emission.  The  emission  occurred  shortly  after  a  vigor- 
ous stripping  of  the  vesicle,  a  process  which  will  be  de- 
scribed. At  the  time  of  the  stripping  considerable 
bloody  material  had  been  forced  out  of  the  duct.  It  is 
probable  that  the  manipulation  had  aided  largely  in  dis- 
lodging the  calculus. 

The  effect  of  the  pathological  factors  just  enumerated 
on  the  constituent  parts  will  now  be  considered. 

The  Semen.  This  fluid  apparently  retains  its  normal 
alkaline  reaction,  though  in  other  respects  pathological. 
The  author  has  tested  this  point  in  many  diseased  con- 
ditions, and  has  invariably  found  it  alkaline. 

The  investigation  was  undertaken  in  order  to  ascer- 
tain if  death  of  the  spermatozoa,  such  as  exists  frequently 
in  diseased  conditions,  depended  on  changes  causing 
acidity  of  the  semen,  it  being  well  known  that  such 
changes  would  in  themselves  be  fatal  to  those  organisms. 
As  these  chemical  changes  were  not  found  to  exist,  death 
in  this  connection  must  be  attributed  to  other  agencies. 

Abnormal  coloring  of  the  semen  depends  on  blood  and 
pus  and  rarely,  apparently,  on  indigo.  (See  Morrow's 
article  on  "  Disorders  of  the  Male  Sexual  Organs,"  Mor- 
row's System  of  Genito-  Urinary  Diseases,  etc.,  vol.  i.) 


PATHOLOGY.  69 

The  coloring  lent  by  the  admixture  of  blood  depends  on 
the  amount  of  that  fluid  and  the  length  of  time  that  has 
elapsed  since  the  bleeding  occurred.  If  the  blood  is 
large  in  amount  and  fresh,  semen  may  have  the  exact 
coloring;  of  blood.  The  red  ting-e  varies  froni  this  in- 
tensity,  where  the  hemorrhage  is  severe,  to  a  slight  tinge 
scarcely  discernible  where  it  is  trifling  in  amount.  In 
cases  where  the  admixture  of  blood  is  very  slight  the 
semen  is  not,  as  a  rule,  uniformly  discolored,  but  pre- 
sents little  reddish  specks  marking  clumps  of  red  cor- 
puscles, the  color  of  the  main  body  of  semen  remaining 
normal.  The  same  description  holds  with  reference  to 
cases  where  the  bleeding  is  not  recent,  except  that  in 
these  latter  cases  the  coloring  lent  by  the  blood  is 
changed  from  red,  and  the  reddish  tinges  to  black  or 
coffee-ground  where  the  hemorrhage  has  been  abundant, 
and  to  brownish  or  rusty  tinges  where  it  has  been  of 
less  amount. 

The  coloring  due  to  the  presence  of  pus  depends  on 
the  same  rules  as  relate  to  the  presence  of  blood.  If  the 
admixture  of  pus  is  recent  and  abundant,  the  yellow 
cream  color  characteristic  of  pus  predominates.  If  the 
admixture  is  less,  the  yellow  color  is  less  accordingly. 
If  the  pus  is  old,  a  greenish  hue  takes  the  place  of  the 
yellow.  It  frequently  happens  that  blood  and  pus  both 
co-exist  as  pathological  factors  in  a  given  seminal  speci- 
men. When  such  is  the  case  different  shades  of  color- 
ing result,  as  one  would  expect  from  such  a  blending. 
Morrow  speaks  of  wine-colored  semen  due  to  indigo,  the 
crystals  of  which  can  be  seen  under  the  microscope  ;  and 
of  a  grass-green  semen,  which  is  supposed  to  be  due  to 
a  mixture  of  the  colors  associated  with  pus  and  indigo. 
Ultzmann  has  mentioned  a  blue  semen.  Such  a  color 
might,  perhaps,  be  due  to  an  indigo-blue. 


70  MALE  SEXUAL  ORGANS. 

Variations  in  Consistency.  This  subject  is  of  much 
importance,  as  will  be  seen  in  considering  the  act  of 
ejaculation.  As  a  preliminary  step  in  this  connection 
mention  should  be  made  of  sympexions,  small,  highly 
refractive  amylaceous  particles  seen  only  by  the  aid  of 
the  microscope  and  somewhat  resembling  starch- gran- 
ules. Attention  was  first  called  to  these  bodies  by 
Robin  ( Traite  des  Humeurs,  1867 ;  Art.  Sperme  du, 
Diet.  Encyclopedique),  who  considered  that  they  were 
normal  constituents  of  the  semen,  being  found,  so  he 
thought,  in  all  cases  where  coitus  had  not  been  practised 
for  four  or  five  days.  He  also  considered  them  absent 
in  the  cases  of  boys  and  in  certain  pathological  condi- 
tions. The  author,  however,  is  of  the  opinion  that  these 
little  bodies  are  pathological,  and  that  they,  although  of 
no  special  importance  in  themselves,  are  representative 
of  the  process  about  to  be  considered  of  thickening  or 
gellification  of  the  seminal  fluid.  These  sympexions 
are  generally  found  in  the  glairy  sticky  shreds  such  as 
are  voided  in  the  urine  of  many  individuals,  especially 
of  those  who  are  popularly  supposed  to  be  losing  their 
semen.  Under  the  microscope  these  shreds  are  seen  to 
consist  of  stringy  mucus  containing  in  its  meshes  here 
and  there  lifeless  spermatozoa,  sympexions,  and  pus-cor- 
puscles or  leucocytes,  the  latter  being  more  abundant 
than  one  would  expect  to  see  in  normal  semen.  In- 
vestigation of  the  seminal  vesicles  in  this  class  of  cases 
results,  in  the  author's  experience,  in  finding  them  usu- 
ally more  or  less  congested.  ]STumerous  examinations 
of  freshly  ejaculated  semen  from  individuals  in  health 
have  failed  to  demonstrate  these  particles.  Sympexions 
dissolve  in  weak  solutions  of  acetic  acid  and  in  acid 
urines.  The  mucus  which  envelops  them  seems  to 
protect  them  temporarily  from  solution  in  an  acid  urine. 


PATHOLOGY.  71 

Hence  the  necessity  of  a  speedy  microscopical  examina- 
tion in  such  investigations.  In  many  of  the  cases  in 
which  the  shreds  containing  sympexions  are  found,  and 
oftentimes  in  others  representing  a  light  grade  or  a  qui- 
escent form  of  seminal  vesiculitis,  if  a  stripping  of  the 
vesicles,  such  as  will  be  described  further  on,  is  prac- 
tised, followed  by  micturition,  there  will  appear  in  the 
urine  considerable  quantities  of  material  apparently  of 
the  same  nature  as  these  sympexions.  The  specific 
gravity  of  this  expressed  material,  since  it  is  free  from 
mucus,  is  much  greater  than  that  of  the  urine,  so  that 
it  speedily  sinks  to  the  bottom  of  the  vessel.  Some  of 
this  material  is  voided  in  cylindrical  moulds  of  about 
the  calibre  of  a  knitting-needle,  and  occasionally  ap- 
proaching an  inch  in  length,  though  usually  considerably 
shorter.  These  cylindrical  bodies  are  moulded  by  the 
ejaculatory  ducts.  Most  of  the  material,  however,  ap- 
pears as  globules  and  of  all  sizes  up  to  that  of  a  small 
pea.  The  rotary  motion  imparted  to  it  as  it  is  forced 
along  the  urethra  with  the  urine  is  probably  accounta- 
ble for  the  globular  shape.  These  globules  have  some 
opacity  and  considerable  refraction ;  in  fact,  they  might 
well  be  likened  in  appearance  to  moonstones.  In  a 
minute  or  two  they  all  disappear,  being  dissolved  by 
the  acidity  of  the  urine  in  the  same  manner  as  sym- 
pexions, although  more  readily,  since  they  are  not  pro- 
tected by  mucus,  leaving  a  uniform  opacity  to  the  urine 
at  the  bottom  of  the  vessel.  If,  however,  after  this 
stripping,  instead  of  allowing  the  urine  to  be  voided,  the 
length  of  the  urethra  is  stroked  from  behind  forward 
some  of  the  expressed  material  appears  at  the  meatus 
and  can  be  examined  microscopically.  When  this  is 
done  the  material  is  found  to  be  like  that  making  up 
sympexions.     In  it  are  numerous  dead  spermatozoa  and 


72  MALE  SEXUAL  ORGANS. 

other  elements  such  as  are  fouDd  in  seminal  fluid.  In 
fact,  it  is  nothing  more  than  thick  jellied  seminal  fluid. 
What  the  agent  is  which  causes  this  thickening  of  the 
semen  is  not  known.  It  seems  to  be  associated  with  a 
light  grade  inflammatory  process,  although  possibly  the 
length  of  time  that  the  fluid  has  been  secreted  may  have 
a  bearing  on  the  subject. 

In  severe  inflammatory  processes,  where  there  is  much 
pus,  this  jellification  is  not  found.  In  such  cases,  how- 
ever, inflammatory  exudations  and  desquamations  in 
connection  with  the  lining  mucous  membrane  of  the 
vesicles  and  in  ulcerative  and  malignant  conditions,  de- 
tachments of  necrosed  or  new-growth  material,  may 
render  the  otherwise  fluid  contents  of  the  sacs  of  such 
an  irregular  consistency  that  a  partial  plugging  of  the 
ejaculatory  ducts  ensues.  Bleeding  into  the  cavity  of 
the  vesicle  when  severe  may  be  followed  by  a  clot,  but 
such  an  obstruction  would  be  of  a  temporary  nature,  and 
consequently  does  not  figure  as  an  element  of  impor- 
tance in  this  connection.  Mention  also  need  be  here 
made  of  calculi  as  a  possible  cause  for  obstruction. 
Death  of  the  associated  spermatozoa  apparently  occurs 
as  a  result  of  thickening  and  inflammatory  changes 
generally,  in  connection  with  the  seminal  fluid. 

The  Walls  of  the  Seminal  Vesicles.  As  a  result  of  the 
pathological  processes  already  considered,  these  walls 
may  become  thickened,  associated  with  contraction  or 
distention  of  the  cavity,  or  thinned,  with  distention  of 
the  sac.  Thickening  is  in  large  measure  due  to  in- 
flammatory infiltration  into  the  submucous  connective 
tissues,  and  also  to  a  less  extent  into  the  intramuscular 
connective  tissues.  In  some  cases  muscular  hypertro- 
phy accounts  for  a  portion  of  the  thickening,  especially 
where  the  cavity  is  contracted.     It  is  much  more  com- 


PATHOLOGY.  73 

mon,  however,  for  thickening  to  be  associated  with  a 
distention  of  the  cavity  and  with  muscular  atrophy 
rather  than  hypertrophy.  Where  muscular  atony  occurs 
without  inflammatory  infiltration  a  thinning  and  disten- 
tion of  the  sac  results.  In  such  cases,  however,  which 
originate  in  a  lack  of  muscular  tonicity,  inflammatory 
infiltration  is  liable  to  occur  as  a  later  result.  Rarely 
thinning  of  the  walls  may  result  from  ulcerative  pro- 
cesses, as  in  acute  tuberculosis  of  the  part.  In  all  these 
inflammatory  conditions  distention  of  the  cavity  of  the 
sac  is  the  rule,  owing  to  the  changes  in  the  semen  and  in 
the  vesicular  contents,  which  make  its  ejaculation  diffi- 
cult. In  this  connection  also  the  mucous  lining  should 
be  studied.  Besides  modifications  in  its  natural  secre- 
tion, blood  and  pus  result  from  inflammations  affecting 
it.  Blood  appears  usually  in  acute  or  very  chronic  con- 
ditions, also  as  the  result  of  ulceration.  In  acute  in- 
flammation the  bleeding,  which  is  liable  to  be  small  in 
amount,  depends  on  the  engorgement  of  the  normal 
capillaries.  In  very  chronic  states  the  long-standing 
congestion  of  these  small  vessels  leads  to  their  perma- 
nent dilatation  and  hypertrophy.  When  such  is  the 
case  a  little  strain  or  pressure  may  easily  cause  a  rup- 
ture from  which  a  hemorrhage,  occasionally  considerable 
in  amount,  may  result.  The  appearance  of  blood,  there- 
fore, in  these  latter  conditions  is  liable  to  be  periodical 
or  occasional.  The  amount  of  pus  secreted  depends 
largely  on  the  severity  of  the  inflammatory  process,  be 
it  acute  or  chronic,  little  pus  resulting  from  the  mild 
grades.  It  is  probable  that  other  changes  in  connection 
with  this  mucous  membrane  occur  similar  to  those  asso- 
ciated with  the  mucous  membrane  of  the  bladder,  but 
as  yet  there  has  been  no  demonstration  of  this  fact. 
Finger  {Internal.  Min.  Rundschau,  Wien,  February  12, 


74  MALE  SEXUAL  ORGANS. 

1893)  holds  that  chronic  inflammatory  processes  involv- 
ing the  ejaculatory  duct  by  extension  from  the  urethra 
cause  a  marked  stenosis  of  its  calibre.  Such  stenosis 
results,  so  he  considers,  from  inflammatory  exudations 
into  their  walls,  followed  by  connective-tissue  prolifera- 
tion. Although  agreeing  with  Finger  as  regards  the 
inflammatory  extension,  still  the  author  has  failed  to 
confirm  his  conclusions  regarding  stenosis,  having  never 
as  yet  encountered  a  case  of  seminal  vesiculitis  associ- 
ated with  distention  of  the  sac  in  which  it  was  not  an 
easy  matter,  as  a  result  of  proper  manipulation,  to  press 
out  the  inflamed  mass  along  the  ejaculatory  duct.  In 
most  such  instances,  also,  an  examination  of  the  ex- 
pressed material  will  show  either  moulds  indicative  of  a 
good-sized  calibre  of  the  duct,  or  masses  of  material 
such  as  could  not  have  been  expressed  had  there  ex- 
isted a  stricture  of  the  duct.  The  supposition  that 
stenosis  would  result  as  an  after-effect  of  inflammation 
in  these  ducts  is  plausible.  That  such  apparently  does 
not  result,  at  least  in  the  author's  experience,  is  prob- 
ably due  to  the  anatomical  arrangement.  These  ducts 
are  not  imbedded  in  connective  tissue,  but  lie  in  the  in- 
fundibulum  of  the  prostate,  a  lymph-space,  as  it  were. 
Consequently  the  greater  part  of  an  inflammatory  infil- 
tration would  enter  the  lymph-space,  and  would  not 
remain  packed  about  the  ducts  in  a  loose  tissue,  eventu- 
ally to  create  a  connective-tissue  proliferation. 

Another  very  strong  argument  against  stenosis  of 
these  ducts  as  a  result  of  inflammation  lies  in  the  fact 
that  cystic  tumors  originating  from  a  retention  of  the 
vesicular  contents,  due  to  occlusion  of  the  ejaculatory 
ducts,  have  never  as  yet  been  conclusively  demonstrated 
to  exist.  Guelliot,  whose  work  has  already  been  re- 
ferred to,  after  a  thorough  search  of  the  literature,  has 


PATHOLOGY.  75 

found  only  two  cases  bearing  on  this  point,  and  with 
regard  to  these  there  was  much  doubt,  as  the  surgeons 
who  reported  them  simply  supposed  them  to  be  such 
cases  from  the  clinical  evidences  presenting.  Cysts  in 
connection  with  what  remains  of  the  embryonic  ducts 
of  Miiller  do  occasionally  occur,  and  as  such  cysts 
would  naturally  encroach  on  the  territory  of  the  sem- 
inal vesicles,  it  is  reasonable  to  suppose  that  these  two 
cases,  as  other  similar  obscure  cysts  of  this  region,  may 
have  originated  in  these  embryonic  structures,  echino- 
coccus  cysts,  of  course  the  common  form  in  this  situation, 
having  been  diagnostically  excluded.  W.  T.  Bel  field, 
of  Chicago  (Journal  of  the  American  Medical  Associa- 
tion, Chicago,  April  21, 1894),  in  a  very  instructive  arti- 
cle, after  considering  the  embryology  of  the  organs  of 
Wolff  and  Miiller,  records  a  number  of  cases  where 
cysts  of  the  post-prostatic  region  occurred,  the  walls  of 
which  were  made  up  of  the  portion  of  the  duct  of  Miil- 
ler remaining  pervious  and  unatrophied.  In  some  of 
these  cases  the  lower  portion  of  the  duct  is  not  sealed, 
but  communicates  with  the  bladder,  in  which  instances 
there  exists  a  vesical  pouch  in  the  place  of  a  cyst. 

That  inflammatory  processes  rob  the  seminal  ducts  of 
their  natural  elasticity  and  render  them  unyielding,  so 
that  they  offer  considerable  resistance  to  the  passage  of 
semen,  is  probable,  and  such  is  the  author's  view  of  the 
question.  It  seems  possible,  however,  to  restore  at  least 
in  great  measure  this  lost  elasticity. 

Perivesicular  Inflammations.  Such  inflammations  are 
common  and  their  results  important  in  connection  Avith 
sexual  disturbances.  Noel  Halle  (Annal.  des  Malad. 
des  Organ.  Gfenito-Urinaires,  Paris,  Nov.  and  Dec. 
1892)  has  recently  treated  the  subject  of  inflammations 
involving   the  connective   tissues   outside   the  bladder 


76  MALE  SEXUAL   ORGANS. 

walls  (perivesical  inflammations)  in  a  thorough  manner. 
In  this  investigation  Halle  was  apparently  struck  by 
the  frequency  with  which  inflammatory  conditions  in- 
volved the  connective  tissues  at  the  vesical  base,  especi- 
ally as  he  located  them  in  the  wedge-shaped  space 
between  the  ureters  and  the  bladder- wall,  the  interven- 
ing space  between  the  ureters  apparently  being  less 
liable  to  such  invasion.  The  author,  as  a  result  of  clini- 
cal experience,  felt  convinced  that  most  of  the  cases 
alluded  to  by  Halle  as  representative  of  a  perivesical 
inflammation  involving  the  space  between  the  bladder 
and  the  ureter  were  cases  of  peri  vesicular  inflammation. 
In  other  words,  that  most  of  the  inflammatory  condi- 
tions discovered  bore  a  relation  as  far  as  their  origin 
was  concerned,  not  to  the  bladder  or  to  the  ureter,  but 
solely  and  only  to  the  seminal  vesicle.  In  order  to  verify 
this  opinion,  derived  from  clinical  study,  the  author 
made  numerous  pathological  investigations  which  show 
that  such  inflammations  of  the  connective  tissue  are 
really  focused  about  chronically  inflamed  vesicles.  Plates 
VII.  and  VIII.  represent  this  condition  in  a  marked 
degree,  the  inflammation  being  chronic  and  extensive. 
They  both  represent  different  views  of  the  same  speci- 
men. 

Plate  VII.  A  represents  the  anus ;  B,  the  cut  sec- 
tion through  the  bowel,  five  or  six  inches  above  the 
anus ;  C,  the  urethra ;  D,  the  bladder ;  K,  the  right 
seminal  vesicle ;  J,  the  right  vas  deferens.  A  cut  has 
been  made  through  the  sclerosed  tissue  down  to  and 
partially  denuding  the  seminal  vesicle.  The  loosened 
flap  of  this  hardened  mass  has  then  been  pulled  forward 
by  means  of  a  thread  which  does  not  appear  in  the  plate, 
thus  exposing  a  portion  of  the  vesicle.  The  exposed 
portion  of  the  vesicle  is  not  in  its  proper  position,  but 


PLATE    VII 


Chronic  perivesicular  inflammation — right  side. 


PLATE    VIII, 


Chronic  perivesicular  inflammation — left  side. 


PATHOLOGY.  77 

has  also  been  pulled  forward  by  the  traction  exerted  by 
the  thread.  The  walls  of  the  vesicle  are  seen  to  be 
fibrous  and  thickened,  and  they  are  so  firmly  imbedded 
in  the  perivesicular  mass  that  it  is  only  with  the  great- 
est difficulty  that  they  can  be  dissected  free  from  it. 
The  extent  of  the  perivesicular  induration  is  consider- 
able. It  fills  up  the  recto-vesical  space,  beginning  in 
front  at  the  posterior  limits  of  the  prostate  and  extend- 
ing back  to  the  peritoneal  deflection.  It  also  extends 
upward  beyond  the  recto-vesical  space,  involving  the 
perivesical  tissue  at  the  side  of  the  bladder.  This  in- 
flamed tissue  is  very  hard  and  unyielding  to  the  touch. 
It  does  not  consist  wholly  of  fibrous  tissue,  but  in  the 
meshes  there  is  considerable  hard  fat-tissue. 

Plate  VIII.  This  plate  represents  the  left  side  of 
the  specimen.  As  in  Plate  VII.,  A  represents  the  anus ; 
B,  the  cut  section  of  the  rectum,  five  or  six  inches  above 
the  anus ;  C,  the  urethra ;  D,  the  bladder ;  K,  the  left 
seminal  vesicle ;  J,  the  left  vas  deferens.  A  dissection 
has  been  made  through  the  sclerosed  mass  down  to  and 
partially  denuding  the  vesicle,  just  as  was  made  and  de- 
scribed in  Plate  VII.,  with  the  exception  that  in  Plate 
VIII.  the  loose  flap  after  being  pulled  forward  has  been 
tacked  down,  instead  of  being  held  in  position  by  the 
traction  exerted  by  a  thread.  In  this  plate  the  dense 
thickening  of  the  walls  of  the  seminal  vesicle  shows  to 
better  advantage  than  in  Plate  VII.  The  perivesicular 
infiltration  and  sclerosis  are  not,  however,  so  extensive  nor 
so  bulky  on  this  side  as  on  the  other.  As  has  been  said, 
the  inflammation  just  illustrated  represents  a  chronic 
stage.  In  its  early  stage  these  perivesicular  tissues  were 
invaded  by  a  serous  inflammatory  exudation  originat- 
ing from  the  vesicular  walls,  the  primary  focus  of  in- 
flammation.    This  exudation  caused  a  condition  of  hard 


78  MALE  SEXUAL   ORGANS. 

oedema.  As  a  next  step,  inflammatory  changes  in  the 
connective  tissue  invaded  by  the  exudation  occurred  as 
a  result  of  this  invasion.  Then  these  inflammatory 
changes  in  their  turn  resulted  in  a  proliferation  and  con- 
traction of  this  tissue,  thereby  squeezing  out  the  oedema 
and  leaving  the  condition  which  appears  in  the  engrav- 
ings. Such  is  a  description  of  most  inflammations  of 
the  perivesicular  tissues.  Sometimes,  however,  in  severe 
conditions  the  exudation  is  not  serous  but  purulent. 
When  such  is  the  case,  pus-foci  are  found  in  the  peri- 
vesicular tissues.  Those  foci  are  generally  small  and 
do  not  communicate,  being  eventually  absorbed,  leaving 
as  a  result  an  extra  amount  of  connective-tissue  infiltra- 
tion and  sclerosis.  Sometimes,  however,  they  form  in- 
tercommunications more  or  less  extensive,  due  to  the 
breaking  down  of  the  intermediate  tissues,  abscesses  of 
greater  or  less  size  resulting.  Many  such  abscesses 
when  not  absorbed  probably  discharge  into  the  vesicle 
or  into  the  bladder.  Pathological  investigations  in  re- 
gard to  these  abscesses  are  at  present  very  limited.  It 
is  probable,  however,  that  many  of  the  extensive  pelvic 
pus-formations,  such  as  are  occasionally  encountered, 
and  which  may  communicate  with  the  bowel  or  bladder, 
have  their  source  in  perivesicular  inflammations.  Most 
of  the  so-called  prostatic  abscesses  which  finally  termi- 
nate by  discharging  themselves  into  the  bladder  are 
presumably  perivesicular  in  character.  Mention  has 
already  been  made  of  the  fact  that  perivesicular  inflam- 
mations when  acute  or  extensive  may  involve  the  peri- 
toneum. The  resulting  peritonitis  is  generally  circum- 
scribed and  serous.  Instances,  however,  have  been 
reported  (see  Guelliot,  already  referred  to)  where  it  has 
been  purulent  and  general.  Gonorrhoea  is  the  usual 
cause  in  such  instances.    Acute  perivesicular  inflamma- 


PATHOLOGY.  79 

tions  are,  as  a  rule,  readily  absorbed,  leaving  compara- 
tively little  sclerous  thickening-.  Sometimes,  however, 
they  become  chronic,  associated  with  much  sclerosis, 
especially  in  subjects  tubercularly  inclined. 

After  this  study  the  important  relation  that  patho- 
logical processes,  especially  inflammatory  ones,  bear  to 
the  mechanism  of  ejaculation  can  readily  be  seen.  They 
all  tend  to  interfere  with  that  mechanism,  whether  they 
attack  the  seminal  fluid,  the  ejaculatory  ducts,  the  vesic- 
ular walls,  or  the  perivesicular  tissues,  and  when  they 
involve  one  of  these  parts  severely,  or,  what  is  more 
common,  several  of  them  at  once,  the  effect  may  be  such 
as  to  cripple  that  function.  For  instance,  if  the  seminal 
fluid  becomes  thickened  or  gelatinous,  it  is  ejaculated 
with  greater  difficulty ;  if  the  ejaculatory  ducts  become 
inelastic  and  ridged,  they  offer  an  abnormal  amount  of 
resistance  to  the  passage  of  the  seminal  fluid ;  if  the 
vesicular  walls  are  infiltrated  and  thickened  or  sclerosed, 
they  contract  and  are  compressed  with  difficulty;  if 
perivesicular  infiltration  and  sclerosis  exist,  the  body  of 
the  corresponding  vesicle  is  held,  as  it  were,  in  a  mould, 
and  its  own  muscular  function  as  well  as  that  of  the 
prostate  is  thereby  impaired. 


CHAPTER    IY. 

CLINICAL   FEATURES. 

The  subject-matter  of  this  chapter  can  best  be  treated 
under  the  headings :  (1)  Symptoms,  (2)  Histories,  and 
(3)  Physical  Signs  Resulting  from  Rectal  Exploration. 

Symptoms  may  be  direct  or  indirect.  Direct  symp- 
toms are  largely  localized,  being  confined  to  the  sexual 
organs  or  to  the  organs  adjacent  to  or  connected  with 
them.  They  bear  a  close  relationship  to  the  pathologi- 
cal processes  which  have  already  been  considered.  They 
may  be  inflammatory,  functional,  or  neurotic.  These 
varieties  are  usually  more  or  less  associated  in  a  given 
instance,  at  times  all  three  coexisting,  although  one 
variety  may  be  present  to  the  exclusion  of  the  other 
two.  They  vary  much  in  intensity  with  the  individual 
affected.  The  severity  of  these  subjective  symptoms 
does  not  necessarily  correspond  with  the  severity  of  the 
pathological  condition,  oftentimes  marked  subjective 
symptoms  being  associated  with  a  light  grade  patho- 
logical process.  The  reverse  of  this  statement  may  also 
be  true. 

Indirect  symptoms  consist  of  neurotic  disturbances  of 
a  reflex  nature  in  connection  with  other  parts  and  of 
mental  disturbances.  Such  symptoms  depend  on  dis- 
turbances in  the  seminal  vesicles,  although  oftentimes 
at  first  sight  a  demonstration  of  this  may  be  impossible. 
That  it  is  the  case,  however,  is  frequently  proven  by 
the  fact  that  these  symptoms  disappear  as  resolution 
resulting  from  treatment  takes  place  in  the  vesicles. 


CLINICAL  FEATURES.  81 

Acute  Seminal  Vesiculitis.  DIRECT  SYMPTOMS.  Ill 
this  disease  the  direct  symptoms  are  almost  wholly  in- 
flammatory, neurotic  and  functional  features  being  at  a 
minimum.  It  is  accompanied  with  temperature,  acute 
pain,  and  tenderness.  The  pain  is  usually  referred  to 
the  right  or  left  supra-pubic  region  corresponding  to  the 
involved  vesicle,  and  often  also  to  the  sacrum.  From 
this  region  as  a  focus  it  frequently  radiates  along  the 
spermatic  cord  and  down  to  the  testicle,  although  those 
parts  may  not  be  involved  by  an  extension  of  the  in- 
flammation. When  the  pain  so  radiates  the  correspond- 
ing testicle  may  be  retracted  during  a  paroxysm.  Then, 
again,  it  may  radiate  upward  toward  the  corresponding 
kidney.  It  is  not  rare  with  this  disease  to  have  the  pain 
reflected  in  the  kidney  region  so  severe  and  persistent 
that  it  is  mistaken  for  pain  due  to  pyelitis.  It  may 
also  be  reflected  toward  the  vesical  neck  and  along  the 
urethra.  As,  however,  these  parts  are  frequently  in- 
volved in  this  disease,  with  an  active  inflammation  in 
common  with  the  vesicle,  the  pain  in  them  is  not  always 
of  a  reflex  character.  But  at  times  the  inflammation 
along  the  urinary  tract  has  spent  itself  before  the  vesi- 
cle is  involved.  In  such  instances  severe  pain  in  this 
locality  is  evidently  largely  if  not  wholly  reflex  in  char- 
acter. Pain  in  connection  with  the  urinary  tract  is 
often  associated  seemingly  with  the  act  of  micturition. 
This  act  at  such  times  is  accompanied  with  pain  along 
the  canal,  the  desire  to  urinate  being  frequent  and 
urgent.  At  the  end  of  the  act  severe  pain  at  the  meatus, 
at  the  vesical  neck,  or  at  both  those  parts  at  once,  may 
occur.  From  what  has  been  said  it  must  not  be  inferred 
that  the  urinary  act  is  necessarily  stimulated  in  these 
cases,  for  the  opposite  may  occur,  it  being  very  tardy 
and  infrequent,  and  unassociated  with  disagreeable  sen- 


82  MALE  SEXUAL  ORGANS. 

sations.     Sometimes,  too,  voiding  of  urine  is  difficult  of 
accomplishment,  the  stream  being  very  fine  or  perhaps 
dribbling.     Under  these  circumstances  the  harder  the 
patient  strains  in  his  attempt  to  micturate  the  worse 
the  stream.     This  condition  is  brought  about  largely 
by  reflex  urethral  spasm  due  to  the  vesiculitis,  though, 
as  will  be  mentioned  under  complications,  inflammatory 
tumefaction  may  also  play  a  part.      Gentle  palpation 
on  the  affected  side  above  the  pubes  reveals  great  ten- 
derness and  abdominal  muscular  rigidity  over  the  area 
involved.    If  the  pressure  is  at  all  severe,  active  painful 
sensations  are  awakened.    Rectal  distention,  either  fecal 
or  flatulent,  shows  this  part  to  be  very  tender.     The 
natural  passage  of  flatus  or  the  drawing  it  off  through 
a  tube  gives  relief.     So,  also,  does  the  natural  evacua- 
tion of  the  bowel  if  not  attended  with  straining ;  other- 
wise the  pain  occasioned  by  the  straining  offsets  the 
relief  caused  by  the  evacuation.    Occasionally  the  tume- 
faction due  to  the  disease  gives  rise  to  a  feeling  of  rectal 
distention.    If,  under  these  conditions,  attempts  at  defe- 
cation are  made  and  persisted  in,  an  aggravation  of  the 
symptoms,  together  with  much  pain  and  tenderness,  re- 
sults.   In  these  cases,  also,  it  is  usual  for  the  patient  to  de- 
rive some  comfort  by  maintaining  the  thigh  more  or  less 
flexed,  thereby  diminishing  somewhat  the  tension  of  the 
abdominal  structures.     The  temperature  in  these  cases 
during  their  intensity  commonly  ranges  between  100° 
and  104°.    In  this  disease  temperature,  pain,  and  tender- 
ness are  very  closely  related  to  the  amount  of  inflam- 
matory distention  existing  in  the  vesicular  sac.     While 
purulent  material  is   collecting  in  the  sac,  and  is  not 
being  discharged,  all  three  of  these  symptoms  are  on 
the  increase,  reaching  their  maximum  at  the  period  of 
greatest  distention.     When  the  sac  begins  to  discharge 


CLINICAL  FEATURES.  83 

itself  by  the  way  of  the  ejaculatory  duct,  as  is  usual, 
passively,  and  not  associated  with  any  apparent  act  of 
ejaculation,  the  opposite  state  of  affairs  ensues,  the  three 
inflammatory  symptoms  decreasing,  the  amount  of  de- 
crease being  regulated  by  the  freedom  and  extent  of  the 
drainage.  Thus  it  is  that  watching  the  urine  is  impor- 
tant. This  fluid  is  usually  quite  clear,  sometimes  per- 
fectly so,  while  the  inflammatory  symptoms  are  severe, 
it  becoming  cloudy  and  purulent  with  the  decrease  of 
the  symptoms  as  an  escape  of  pus  from  the  vesicular 
cavity  occurs. 

Xeurotic  disturbances  in  this  condition  are  confined 
to  the  radiating  pains  which  have  already  been  men- 
tioned. Functional  symptoms,  as  has  been  said,  are 
slight.  In  the  first  stage  of  the  disease  erections,  emis- 
sions and  other  evidences  of  sexual  excitement  may 
exist,  but  they  usually  promptly  disappear,  inflamma- 
tory symptoms  taking  their  place  as  the  trouble  pro- 
gresses. This  is  natural,  as  the  sexual  function  is 
usually  in  abeyance  in  febrile  states.  "When  emissions 
do  occur,  they  may  be  bloody  or  discolored  by  little 
streaks  of  blood.  Their  purulent  character,  however, 
is  the  important  feature;  but  this  is  generally  over- 
looked, as  no  unusual  stain  is  left.  They  are  associated 
wTith  pain  sometimes  extremely  acute  in  character. 

Such  are  the  symptoms  of  a  simple  acute  vesiculitis. 
In  these  cases,  however,  complications  are  frequent  and 
need  consideration.  Involvement  of  the  corresponding 
epididymis  and  cord  by  an  extension  of  the  inflamma- 
tion is  common.  Regarding  the  epididymis  in  this  con- 
dition, little  need  be  said,  as  inflammatory  troubles  of 
this  part  are  so  generally  understood ;  but  with  reference 
to  the  cord  some  mention  should  be  made.  This  part 
may  be  so  involved  in  severe  inflammations  as  to  ap- 


84  MALE  SEXUAL  ORGANS. 

proach  in  size  the  little  finger.  When  such  is  the  case, 
although  the  cord  is  tender,  still  the  acute  symptoms 
resulting  do  not  arise  from  the  cord  itself,  but  from  the 
fact  that  owing  to  its  great  increase  in  size  it  fills  tightly 
the  inguinal  canal,  thus  tending  to  squeeze  the  accom- 
panying nerves  between  it  and  the  walls  of  the  canal. 
The  results  of  such  a  condition  are  severe  neuralgic 
pains  in  the  inguinal  region,  which  usually  radiate  down 
the  inner  side  of  the  thigh.  Any  movement  of  the  thigh 
or  testicle  tends  to  aggravate  this  neuralgia. 

It  is  unusual  also  in  this  disease  for  the  inflamma- 
tion to  confine  itself  to  the  vesicle  proper,  but  it  may 
invade  the  perivesicular  tissues.  Occasionally  this 
invasion  is  so  extensive  that  it  can  be  felt  as  a  tumor 
on  making  abdominal  palpation.  In  order,  however,  to 
feel  this  tumor,  even  in  cases  where  it  is  extensive,  it 
may  be  necessary  to  employ  an  anaesthetic  to  overcome 
muscular  rigidity,  and  even  then  it  may  not  be  possible 
to  demonstrate  anything  should  the  subject  be  fat. 
"When  this  complication  is  extensive  the  inflammatory 
symptoms  which  have  already  been  described  are  usu- 
ally intensified,  and  convalescence  is  tardy.  The  peri- 
toneum also  may  be  involved  in  such  cases,  circum- 
scribed pelvic  peritonitis  with  its  associated  symptoms 
resulting.  Such  peritonitis  is  usually  serous  and  cir- 
cumscribed. Under  favorable  circumstances,  however, 
it  may  gradually  become  quite  extensive,  and  occasion- 
ally even  general.  Instances  have  been  reported  where 
it  has  been  general  and  purulent.  In  such  instances, 
however,  it  is  probable  that  the  peritoneal  cavity  was 
invaded  by  pus  breaking  into  it  from  an  abscess  in  this 
part,  in  which  case  the  peritonitis  would  be  general 
almost  from  the  commencement.  When  pus  accumu- 
lates in  the  perivesicular  tissues,  as  may  occur  when 


CLINICAL  FEATURES.  85 

this  complication  is  severe,  it  is  very  unusual  for  it  to 
find  vent  into  the  peritoneal  cavity.  It  oftentimes  be- 
comes quiescent  and  is  gradually  absorbed,  or  it  may 
burst  into  the  vesical  cavity,  there  being  a  sudden  great 
relief  of  symptoms  associated  with  an  abundance  of 
pus  in  the  urine.  It  may  also,  although  this  is  infre- 
quent, discharge  into  the  rectum.  Rare  instances  of 
urine  leakage  into  the  rectum  after  symptoms  corre- 
sponding to  those  of  acute  vesiculitis  probably  repre- 
sent cases  where  such  an  abscess-formation  has  dis- 
charged itself  into  both  bladder  and  bowel,  a  fistula 
resulting.  It  is  usual  for  the  prostate  gland  to  become 
inflamed  in  this  disease.  It  is  difficult  to  decide  whether 
such  inflammation  of  the  prostate  should  be  classed  as 
a  coincident  independent  inflammation  or  as  a  secondary 
one.  It  usually  appears  to  be  an  independent  inflamma- 
tion due  to  the  same  cause  which  occasions  the  vesicu- 
litis. Sometimes,  however,  the  gland  becomes  involved 
by  an  extension  of  the  perivesicular  inflammation,  in 
which  instances  it  is  secondary  to  and  dependent  on  the 
vesiculitis.  In  cases  of  acute  seminal  vesiculitis,  where 
there  is  much  tumefaction  in  the  region  of  the  vesical 
neck,  as  would  occur  should  the  inflammation  compli- 
cate the  prostate,  especially  with  elderly  individuals 
already  afflicted  with  a  certain  degree  of  chronic  hyper- 
trophy of  that  gland,  or  should  a  perivesicular  abscess 
tend  to  point  in  this  region,  retention  of  urine  may  occur. 

A  few  cases  of  pyaemia  have  been  reported  which 
apparently  originated  in  an  acute  seminal  vesiculitis 
complicated  by  a  severe  grade  of  perivesiculitis.  Indi- 
rect neurotic  symptoms  have  not  been  noticed  in  con- 
nection with  this  form  of  vesiculitis. 

History.  With  these  cases  one  almost  always  finds 
associated  an  urethral  2'onorrhceal  infection.     The  2fon- 


86  MALE  SEXUAL   ORGANS. 

orrhcea  is  generally  in  an  acute  stage  when  it  extends 
to  the  vesicle.  As  immediate  causes  for  this  extension 
are  found  alcoholic  stimulation,  coitus,  masturbation, 
sexual  excitement  or  abuse  in  some  form,  exercise  as 
horseback-riding,  bicycle-riding,  etc.,  which  specially 
tend  to  irritate  the  perineal  region ;  also  occasionally  a 
long  railroad  journey,  continuous  vibration  and  jarring 
here  being  the  active  factors.  Urethral  instrumenta- 
tion, injection,  or  local  medication  may  also  act  as  an 
immediate  cause,  generally  when  undertaken  injudici- 
ously during  the  acute  stage  of  gonorrhoea,  although  at 
times  acute  inflammation  of  the  vesicle  may  result  from 
urethral  surgical  procedures  when  undertaken  appa- 
rently most  judiciously,  all  acute  and  infectious  evi- 
dences of  a  preceding  gonorrhoea  having  disappeared. 
When  such  is  the  case,  however,  a  strong  suspicion 
arises  that  there  already  existed  a  subacute  inflamma- 
tion of  the  sac,  which  was  suddenly  stirred  into  activity 
by  the  instrumentation.  For  this  reason  it  is  always 
well  to  acquaint  one's  self  with  the  condition  of  the  vesi- 
cles before  attempting  a  course  of  instrumentation. 
Rarely  an  acute  gonorrhoea  may  extend  to  the  vesicle, 
setting  up  an  intense  inflammation,  without  there  being 
apparently  any  predisposing  cause.  The  author  has  in 
mind  the  case  of  a  boy,  sixteen  years  old,  who  was  put 
to  bed  on  the  first  appearance  of  a  gonorrhoea,  and  in 
whose  case  the  most  conservative  and  careful  treatment 
was  employed,  no  urethral  injections  or  instrumentation 
being  attempted.  Nevertheless,  at  the  end  of  the 
second  week  a  double  acute  vesiculitis  complicated  with 
a  double  epididymitis  occurred.  It  is  possible  that  this 
boy  may  have  caused  this  complication  by  practising 
masturbation ;  but  as  a  nurse  was  in  attendance  all  the 
time  there  was  offered  comparatively  little  opportunity 


CLINICAL  FEATURES.  87 

for  this  practice.  As  has  been  stated,  a  subacute  vesi- 
culitis may  be  stirred  into  an  acute  condition  by  urethral 
surgical  procedures.  The  same  may  also  happen  under 
similar  conditions  as  a  result  of  the  other  factors  which 
have  already  been  enumerated  as  being  immediate  causes 
for  acute  vesiculitis  during  the  active  stage  of  gonor- 
rhoea. Acute  vesiculitis,  however,  as  the  immediate  re- 
sult of  these  latter  factors,  independent  of  a  gonorrhoea, 
is  very  rare.  When  acute  vesiculitis  does  occur  un- 
associated  with  acute  gonorrhoea  the  individual  so 
affected  is  liable  to  be  strumous  if  not  actually  tuber- 
cular, and  it  is  not  unusual  to  find  that  the  underlying 
inflammatory  condition  of  the  vesicle  is  tubercular  in 
character.  Acute  vesiculitis,  non-gonorrhoeal  in  char- 
acter, does  not  represent  so  severe  a  grade  of  inflamma- 
tion as  the  gonorrhoeal  variety. 

Physical  Signs  Resulting-  from  Rectal  Ex- 
ploration". Owing  to  the  sensitiveness  of  the  parts 
and  to  the  great  pain  occasioned  by  digital  rectal  explo- 
ration in  acute  vesiculitis,  the  knowledge  obtained  from 
this  procedure  in  acute  conditions  is  not  nearly  so  great 
or  so  precise  as  that  obtained  in  subacute  and  chronic 
ones.  It  reveals,  however,  in  an  uncomplicated  case 
much  tumefaction  and  tenderness  situated  above  the 
prostate  and  to  one  or  both  sides  corresponding  to  the 
position  of  the  vesicle  or  vesicles  involved.  This  tume- 
faction extends  back  beyond  the  reach  of  the  finger.  If 
the  inflammation  is  largely  confined  to  the  vesicle,  the 
tumefaction  feels  like  a  sausage  under  the  rectal  struct- 
ures. On  pressure  it  seems  doughy  and  oftentimes 
indistinctly  fluctuating.  When  such  pressure  is  made 
much  pain  is  experienced,  together  usually  with  a  sen- 
sation of  urethral  fulness.  Accompanying  this  urethral 
sensation  a  free,  sticky,  purulent  flow  from  the  meatus 


88  MALE  SEXUAL   ORGANS. 

is  usual.  In  such  an  uncomplicated  case  the  prostate 
is  generally  somewhat  enlarged,  showing  congestion, 
and  pressure  upon  it  so  as  to  disturb  the  ejaculatory 
ducts  causes  sharp  pain.  Lateral  pressure,  however,  is 
not  painful.  But  in  many  of  these  cases,  especially 
where  the  acute  process  is  of  some  duration,  the  inflam- 
mation extends  outside  the  vesicle,  involving  extensively 
the  perivesicular  tissues,  and  oftentimes  the  prostate, 
particularly  if  rectal  or  vesical  straining  is  a  feature. 
Under  these  conditions  the  whole  space  between  the 
rectum  and  the  neck  of  the  bladder  may  present  to  the 
feel  a  vast  tumefaction.  Maximum  tenderness,  however, 
is  developed  when  pressure  is  exerted  over  the  region  of 
the  vesicle.  Such  cases  have  usually  been  considered 
to  represent  prostatitis,  the  origin  of  the  inflammation 
having  been  overlooked.  It  is,  as  a  rule,  easy  to  de- 
monstrate the  seat  and  source  of  the  inflammation, 
however,  by  rectal  explorations  practised  during  con- 
valescence, for  then  the  inflammatory  exudation  in  con- 
nection with  the  adjacent  structures  being  in  large 
measure  the  first  to  be  absorbed  the  original  tumefaction 
in  connection  with  the  vesicle  can  be  demonstrated. 

Subacute  and  Chronic  Seminal  Vesiculitis.  DlRECT 
Symptoms.  As  there  is  no  special  difference  in  the 
symptoms  by  which  subacute  vesiculitis  can  be  distin- 
guished from  the  chronic  variety,  unless  it  be  by  their 
duration  and  severity,  it  was  thought  well  in  this  connec- 
tion to  consider  the  two  forms  together.  These  symp- 
toms, especially  the  functional  and  neurotic  ones,  are 
most  varied  and  interesting.  In  fact,  it  was  a  desire  to 
investigate  them  which  prompted  the  author  to  under- 
take the  study,  a  result  of  which  is  this  book. 

Inflammatory  symptoms,  although  of  least  import 
tance,  will  be  considered  first;  in  fact,  with  the  great 


CLINICAL  FEATURES.  89 

majority  of  these  cases  there  are  no  inflammatory 
symptoms,  at  least  none  bearing  an  apparent  connection 
with  the  vesicle.  This  is  one  of  the  probable  reasons 
why  this  form  of  disease  has  been  hitherto  so  generally 
overlooked,  since,  being  pathologically  an  inflammatory 
process,  surgeons  have  sought  inflammatory  symptoms 
before  being  willing  to  admit  of  its  existence.  "When 
inflammatory  symptoms  are  present  they  represent  a 
light  grade  of  the  corresponding  symptoms  associated 
with  the  acute  condition,  and  as  this  subject  has  just 
been  fully  considered  a  complete  repetition  is  not  here 
necessary.  There  are,  however,  some  points  to  be 
noted.  Pain  in  these  conditions  shows  a  tendency  to 
be  reflex  in  character,  and  when  such  is  the  case  will  be 
considered  under  neurotic  symptoms.  When  localized, 
however,  it  is  generally  complained  of  as  being  in  the 
sacral  region  or  above  the  pubes  or  in  the  bladder,  less 
frequently  in  the  rectum  or  in  the  perineum  behind  the 
scrotum.  It  is  intensified  by  sexual  excitement  or 
emotion,  such  factors  sometimes  causing  sharp  parox- 
ysms, which  may  not  wholly  subside  for  several  days. 
Other  factors  which  intensify  these  pains,  although 
usually  to  a  less  degree,  are  constipation  and  diarrhoea, 
together  with  the  consequent  rectal  straining  and  ten- 
esmus, sharp  exercise,  and  sometimes  work  which  entails 
much  bending  forward  of  the  body.  Abdominal  pal- 
pation, unless  very  heavy,  is  not  liable  to  show  much 
tenderness,  and  very  rarely  any  inflammatory  thickening. 
Sometimes,  however,  in  these  cases  tenderness  is  a 
striking  feature.  It  is  then  generally  referred  to  the 
perineum,  any  pressure  there  causing  discomfort  and 
occasionally  severe  pain.  Individuals  so  affected  choose 
a  hard,  smooth  seat,  a  soft,  springy  one  being  avoided. 
Where  this  tenderness  is  extreme  an  inflated  rubber  ring 


90  MALE  SEXUAL  ORGANS. 

is  habitually  taken  about  to  sit  upon,  thus  avoiding  all 
perineal  pressure.  As  a  result  of  these  painful  sensa- 
tions it  is  common  for  the  patient  to  become  convinced 
that  he  has  a  vesical  calculus  or  growth,  a  rectal  tumor, 
hemorrhoids,  prostatic  disease,  or  the  like ;  and  in  the 
hope  of  relief  many  of  these  sufferers  have  submitted 
to  various  operations  on  the  urethra  for  alleged  stricture 
and  on  the  rectum  for  hemorrhoids,  ulcers,  fissures,  etc., 
at  the  hands  of  surgeons  who  lay  more  stress  on  doing 
something  than  on  diagnostic  research.  Fever  is  not  a 
feature  of  this  condition.  When  present  it  is  not  con- 
tinuous, except  occasionally  where  the  process  is  tuber- 
cular, but  paroxysmal,  in  which  instance  it  usually 
announces  itself  by  a  chill.  These  paroxysmal  attacks 
of  fever  may  be  very  severe.  They  are  liable  to  occur 
in  those  cases  of  vesiculitis  complicated  by  germ  infec- 
tion, which  have  been  mentioned  in  studying  the  path- 
ology ;  and  as  a  result  of  some  investigations  undertaken 
by  Dr.  Keyes  and  the  author  the  bacillus  colli  commune 
seems  to  be  the  germ  especially  responsible.  Sometimes 
there  is  no  immediate  apparent  cause  for  a  paroxysmal 
attack  in  these  cases,  but  generally  one  can  find  such  a 
cause  in  a  traumatism,  very  slight  perhaps,  either  in 
connection  with  the  vesicle  or  with  some  part  adjacent 
to  or  connected  with  it.  Chief  among  these  causes  are 
urethral  and  bladder  instrumentations  or  local  medica- 
tions, rectal  disturbances  either  resulting  from  surgical 
procedures  or  from  the  state  of  the  bowels — that  is, 
from  constipation,  impaction,  diarrhoea,  etc.,  together 
with  the  accompanying  straining  and  tenesmus,  and  less 
frequently  exercise  especially  affecting  the  part,  such  as 
shoreback-riding. 

Functional    symptoms    are,  as    has    been   said,  very 
important,  and  among  them  sexual  disturbances  are  of 


CLINICAL  FEATURES.  91 

great  frequency.  Sexual  desire  in  the  majority  of  in- 
stances is  diminished,  in  a  less  percentage  it  is  intensified, 
and  in  a  few  cases  it  is  not  affected.  It  is  not  unusual 
for  intensified  sexual  desire  to  be  a  symptom  of  an 
earlier  stage  of  the  disease,  loss  of  desire  representing  a 
later  stage.  Then,  again,  return  of  desire,  either  normal 
or  intensified,  often  occurs  as  a  result  of  treatment,  and 
may  be  one  of  the  early  favorable  prognostic  signs.  It 
is  of  importance  to  note  that  aversion  to  women  is  no 
feature  of  this  loss  of  sexual  desire,  such  as  may  be 
associated  with  psychological  cases.  Loss  of  desire 
also  has  been  acquired  and  not  inherited.  In  some 
instances  where  desire  has  not  been  lost  it  has  been 
rendered  sluggish,  unusual  and  persistent  means  having 
to  be  employed  in  order  to  arouse  it.  Where  there  is 
intensified  desire  the  degree  may  vary  from  a  slight 
increase  to  instances  where  the  craving  may  be  intense 
and  almost  constant.  Gratification,  however,  derived 
from  intercourse  in  this  condition  generally  bears  an 
inverse  ratio  to  the  intensity — that  is,  gratification  is 
little  or  nothing  in  those  cases  where  the  craving  is 
constant.  From  this,  however,  it  does  not  follow  that 
gratification  is  intensified  in  those  cases  where  the  desire 
is  weakened,  for  such  is  not  the  case,  weakness  and 
diminished  gratification  being  there  corresponding  symp- 
toms. Power  of  erection  corresponds  closely  to  sexual 
desire ;  in  fact,  it  may  almost  be  said  to  be  the  active 
indication  of  sexual  desire.  In  those  cases  where  desire 
is  lost  the  power  of  erection  is  lost,  and  where  it  is  in- 
tensified the  power  of  erection  is  increased,  sometimes 
in  extreme  instances  to  such  an  extent  that  priapism 
becomes  a  very  annoying  and  painful  symptom.  A 
common  cause  for  complaint  regarding  erections  asso- 
ciated with  sexual  weakness  is  not  only  that  they  do  not 


92  MALE  SEXUAL   ORGANS. 

occur,  but  also  that  they  lack  vigor,  the  penis  at  no  time 
being  thoroughly  stiff  and  rigid ;  and  that  they  are  not 
persistent,  but  fail  at  the  critical  moment,  either  as  soon 
as  coitus  is  attempted  or  before  a  satisfactory  comple- 
tion of  the  act  has  been  accomplished,  the  failure  being 
accompanied  in  this  latter  instance  by  an  incomplete 
ejaculation.  Derangements  in  connection  with  seminal 
emissions  are  important.  There  are  very  few  cases  of 
this  disease  where  at  some  period  of  their  course  emis- 
sions have  not  been  a  cause  for  complaint.  The  grounds 
for  complaint  with  reference  to  them  are  that  they  are 
too  frequent ;  that  they  result  from  an  insufficient  ex- 
citing cause  or  before  a  sufficient  cause  has  had  a  proper 
opportunity  to  act ;  that  they  occur  spontaneously,  there 
being  no  real  cause ;  that  they  are  very  tardy  or  do  not 
occur  at  all ;  that  when  they  occur  the  muscular  action 
apparently  is  incomplete,  little  or  no  ejaculation  result- 
ing ;  that  they  are  followed  by  or  associated  with  pain, 
sometimes  intense,  though  generally  dull  in  character, 
resembling  one  of  the  varieties  of  vesicular  pain  which 
have  already  been  considered,  or  that  they  are  followed 
by  a  feeling  of  depression  and  weight  and  not  of  satis- 
faction and  pleasure  such  as  is  natural ;  and  that  their 
color,  or,  what  is  more  usual,  the  stain  left  by  them,  is 
abnormal.  When  the  complaint  is  that  they  are  too 
frequent  reference  is  usually  made  to  involuntary  noc- 
turnal emissions.  In  this  connection  it  is  well  to  state 
that  the  occurrence  of  such  emissions  as  the  result  of 
erotic  dreams  is  physiological  and  natural,  especially  in 
the  case  of  young,  vigorous  adults,  and  to  a  less  extent 
in  later  life,  where  recourse  to  sexual  intercourse  is 
infrequent  or  irregular.  Physiological  emissions  may 
occur  as  often  as  once  a  week  or  once  in  two  weeks  ; 
then,  again,  two  or  three  may  occur  in  a  group  within  a 


CLINICAL  FEATURES.  93 

day  or  so,  to  be  followed  by  a  considerable  interval  of 
repose.  This  explanation  of  what  is  normal  is  given  in 
order  to  correct  a  common  error,  which  is  that  invol- 
untary emissions,  if  not  in  themselves  pathological,  at 
least  point  in  that  direction.  In  pathological  conditions 
involuntary  emissions  may  occur  nightly  or  oftener, 
frequently  several  times  a  week  over  considerable  inter- 
vals of  time.  Another  point  of  importance  also  with 
reference  to  them  is  that  oftentimes  coitus  has  no  effect 
in  reducing  their  frequency,  just  as  many  or  perhaps 
more  than  usual  occurring  shortly  after  the  sexual  act. 
In  these  instances  the  erotic  dream,  if  present,  is  so  to 
such  a  slight  extent  that  it  is  not  to  be  reckoned  as  a 
feature,  and  the  act  of  ejaculation  may  be  associated 
with  little  or  no  erection ;  in  other  words,  they  occur 
without  sufficient  cause.  It  is  not  essential,  however, 
that  emissions  resulting  from  an  insufficient  cause  should 
be  nocturnal,  for  they  may  occur  while  the  individual  is 
in  an  active  mental  state.  Their  occurrence  under  such 
circumstances  is  liable  to  be  symptomatic  of  an  aggra- 
vated pathological  condition  of  the  vesicles.  With 
individuals  so  affected  oftentimes  the  sight  of  a  vo- 
luptuous woman  in  reality  or  in  picture,  and,  in  fact, 
anything  the  least  suggestive,  may  be  a  sufficient  cause. 
Occasionally  with  these  cases  no  cause  at  all  can  be 
ascribed  for  the  act.  The  class  of  individuals  who 
complain  of  the  emission  taking  place  prematurely  on 
attempting  coitus  may  or  may  not  suffer  from  invol- 
untary emissions.  If  the  premature  act  is  associated 
with  an  increase  in  sexual  desire  or  erections,  involuntary 
emissions  are  apt  to  coexist.  If,  on  the  contrary,  it  is 
associated  with  feeble  desire  and  weak  erections,  they 
are  not  likely  to  coexist.  Occasionally  in  cases  where 
the  sexual  desire  is   slight  the  erections,  though  only 


94  MALE  SEXUAL    ORGANS. 

partial,  are  still  persistent  on  attempting  coitus.  In 
such  cases  the  emission  may  be  very  tardy,  and  at  times 
it  may  not  occur  at  all.  Those  cases  in  which  although 
the  erection  is  strong  yet  there  is  no  emission  are  usually 
psychological.  Then,  again,  and  this  condition  is  more 
common,  an  individual  may  complain  that  habitually 
during  sexual  intercourse  a  feeble  sensation  of  ejacula- 
tion is  experienced,  which  is  succeeded  by  little  or  no 
emission.  These  are  the  cases  in  which  pain  or  a  feeling 
of  discomfort,  depression,  or  lack  of  pleasurable  sensa- 
tion is  apt  to  follow  the  act  of  ejaculation.  The  cases 
in  which  intense  pain  follows  upon  or  immediately  after 
ejaculation  are  those  where  an  insufficient  emission  or 
no  emission  at  all  follows  a  violent  act  of  ejaculation. 
They  have  been  spoken  of  as  spermatic  colic,  and  are 
occasioned  by  some  obstruction  to  the  passage  of  semen 
along  the  ejaculatory  ducts  or  to  some  radical  inter- 
ference with  the  muscular  mechanism.  Of  course,  the 
obstruction  or  interference  would  have  to  be  in  connec- 
tion with  both  vesicles  in  order  entirely  to  prevent  an 
emission.  Such  is  not  usual,  one  only  being  in  most 
instances  at  fault.  The  pain,  however,  in  this  latter 
condition  is  generally  so  acute  and  sudden  as  in  great 
measure  to  arrest  the  ejaculatory  act,  and  hence  little 
emission  results  in  either  condition.  Associated  with 
this  acute  pain  there  is  often  a  feeling  as  if  something 
suddenly  gave  way.  Sometimes  the  ejaculatory  sensa- 
tion may  be  normal  and  yet  no  semen  may  appear  at  the 
meatus.  In  these  cases  the  semen  may  be  ejected  back- 
ward into  the  bladder.  Such  a  condition  of  affairs  may 
exist,  as  has  already  been  seen  in  studying  the  pathol- 
ogy, the  result  of  surgical  procedures  on  the  vesical 
neck.  Bloody  emissions  are  generally  associated  with 
painful  ones,  or  they  may  occur  in  chronic  vesiculitis 


CLINICAL  FEATURES.  95 

from  sexnal  excess  or  from  a  traumatism.  Yellowish  or 
greenish-yellow  stains  indicate  that  the  emission  was 
purulent.  By  this  clinical  investigation  of  the  subject 
of  emissions,  together  with  their  various  associated 
symptoms,  it  is  seen  that  numerous  qualities  indicative 
of  disturbances  in  the  mechanism  of  ejaculation  are 
brought  to  notice.  These  disturbances  are  of  prime 
importance,  as  will  be  noted  in  studying  treatment.  In 
questioning  patients,  therefore,  in  whom  seminal  vesi- 
culitis is  suspected,  it  is  always  well  to  bring  out  the 
particulars  regarding  emissions  and  the  ejaculatory  act, 
such  as  have  just  been  enumerated. 

The  passive  loss  of  semen  unassociated  with  an  emis- 
sion, or,  in  fact,  with  any  sexual  excitement,  is  another 
frequent  cause  of  complaint  in  this  condition.  The 
usual  story  is  that  there  often  appears  at  the  meatus  a 
glairy,  pasty  discharge,  which  the  patient  may  have 
of  his  own  accord  diagnosed  as  seminal  from  its  general 
characteristics.  The  favorite  time  for  the  appearance  of 
this  material  is  described  as  after  a  constipated  or  active 
stool,  the  coincident  straining  and  tenesmus,  together 
with  the  direct  pressure  of  the  fecal  material  on  the 
seminal  vesicles,  being  assigned  as  the  cause.  In  some 
instances  where  this  sticky  discharge  is  slight  it  is  from 
the  prostate  and  indicates  little,  unless  it  be  a  sensitive 
condition  of  that  organ  and  of  the  deep  urethra,  the 
usual  cause  being  over-sexual  excitement  or  indulgence ; 
but  in  those  cases  where  it  appears  in  abundance  as  the 
result  of  the  above-described  bowel  conditions,  it  is  a 
clinical  symptom  of  considerable  value  indicative  of 
seminal  vesiculitis.  The  microscope  is  of  great  aid  in 
settling  the  source  of  such  a  discharge. 

Masturbation  may  be  a  symptom  of  seminal  vesicu- 
litis.    The  author  has  in  mind  a  case  where  it  was  so 


96  MALE  SEXUAL    ORGANS. 

present  to  a  marked  degree,  the  clinical  history  of  which 
will  be  published  later  on  in  this  book  among  illustrative 
cases.  This  symptom  may  be  commoner  than  it  appears 
to  be,  owing  to  the  fact  that  most  individuals  addicted 
to  the  practice  are  secretive  regarding  it.  That  mastur- 
bation was  a  symptom  of  vesiculitis  in  the  author's  case 
was  shown  by  the  fact  that  the  practice  stopped,  together 
with  all  desire  in .  that  direction,  promptly  as  resolution 
resulting  from  treatment  took  place  in  the  vesicles.  In 
the  case  under  consideration  masturbation  was  resorted 
to  in  order  to  quell  a  sensation  of  sexual  craving  asso- 
ciated with  erection  or  a  tendency  to  erection.  This 
sensation  of  craving,  which  was  almost  constant,  was 
intensified  at  times.  During  these  periods  of  intensity, 
provided  coitus  was  impossible,  the  tendency  to  mastur- 
bate would  become  so  strong  that  the  individual  could 
not  resist  it.  The  act  would  be  repeated  several  times, 
very  little  relief  or  satisfaction  with  respect  to  the 
craving,  however,  resulting  from  it.  Sometimes  in  this 
case  the  individual  stated  that  he  would  wake  up  finding 
himself  practising  the  act.  Most  cases  of  excessive  or 
habitual  masturbation  are  psychological.  This  case  will 
be  further  considered  under  differential  diagnosis. 

Curious  sensations,  with  reference  to  the  penis,  the 
testicles,  and  the  scrotum,  are  common.  The  complaint 
may  be  that  the  penis  always  feels  cold  or  numb  and  is 
shrivelled ;  sometimes  that  there  is  a  feeling  as  if  that 
organ  was  foreign,  having  no  real  connection  with  the 
rest  of  the  anatomy.  Then,  again,  there  may  be  a  feel- 
ing of  dragging  or  relaxation  in  connection  with  the 
testicles  and  scrotum.  Sometimes  this  sensation  is 
marked.  At  such  times  considerable  pain  is  apt  to  be 
associated,  so  much  so,  in  fact,  that  a  suspensory- 
bandage  may  be  habitually  worn  in  order  to  secure  some 


CLINICAL  FEATURES.  97 

relief.  Instead  of  feelings  of  relaxation,  those  of  contrac- 
tion of  the  scrotum  and  retraction  of  the  testicles  may 
occur.  In  some  instances  the  retraction  of  the  testicles 
may  be  so  violent  as  to  be  very  painful.  These  opposite 
sensations  of  relaxation  and  contraction  may,  and,  in 
fact,  often  do,  alternate  in  a  given  instance.  In  this 
connection  the  complaint  is  frequent  that  the  testicles 
are  withering,  although  there  is  no  real  evidence  of  this 
fact ;  also  that  the  sensations  experienced  on  the  manip- 
ulation of  them  are  less  acute  than  normal  or  are  strange 
and  unnatural.  In  such  cases  it  is  common  for  the 
individual  or  the  surgeon,  as  the  result  of  an  examina- 
tion of  the  part  with  the  idea  of  finding  in  some  local 
pathological  process  a  cause  for  the  symptoms  com- 
plained of,  wrongly  to  ascribe  everything  unnatural  to 
a  varicocele  or  to  a  cyst,  should  these  formations  hap- 
pen to  be  present. 

Neurotic  sensations  in  connection  with  the  urethra 
and  the  vesical  neck  are  common,  and  frequently  are  the 
features  especially  dwelt  upon  by  individuals  in  the 
clinical  recital  of  their  complaints.  These  sensations 
are  often,  in  the  complainant's  mind,  associated  more  or 
less  with  the  urinary  act.  They  may  be  described  as 
burning  sensations,  of  varying  degrees  of  acuteness, 
extending1  all  along-  the  urethra  during  the  act  of  mic- 
turition,  or  the  point  of  sensation  may  be  localized  in 
some  definite  spot  along  the  urethra,  generally  just  back 
of  the  frsenum.  In  such  instances  the  complaint  is  usual 
that  the  spot  has  the  feeling  of  being  raw,  and  that  in 
micturition,  as  soon  as  the  urine  in  its  outward  flow 
reaches  the  point  in  question,  a  sharp  pain  is  experienced. 
The  individual  in  these  instances  is  usually  so  positive 
about  this  supposed  raw  spot  that  he  insists  not  only  on 
putting  his  finger  on  the  point  on  the  outside  floor  of 


98  MALE  SEXUAL  ORGANS. 

the  urethra,  showing  where  it  is  situated,  but  also  on 
the  surgeon's  making  a  careful  urethral  exploration  of 
the  region,  which,  it  is  needless  to  say,  presents  a  per- 
fectly normal  appearance.  Then,  again,  the  painful 
region  may  be  located  at  the  vesical  neck,  in  which  case 
sensation  is  most  marked  at  the  end  of  the  urinary  act. 
It  is  usual  to  find  that  these  urethral  sensations,  al- 
though apparently  dependent  on  the  urinary  act  or  on 
the  state  of  the  urine,  are,  nevertheless,  most  marked 
after  a  sexual  strain  or  after  sexual  excitement  which 
has  not  been  relieved  by  natural  sexual  intercourse. 
Rarely  a  urethral  reflex  pain  of  this  nature  may  persist 
without  being  aggravated  or  affected  in  any  way  by  the 
urinary  act.  The  author  has  in  mind  a  case  of  this 
description  where  a  painful  spot  in  the  urethra,  asso- 
ciated with  persistent  sexual  craving,  was  very  constant. 
On  attempting  intercourse,  however,  the  power  was 
very  weak.  In  this  case  the  individual  stated  that  the 
only  way  he  knew  of  ridding  himself  of  the  urethral 
pain  was  by  drinking  freely  of  ale,  after  which,  for  the 
time  being,  it  would  disappear,  associated  with  a  tem- 
porary return  of  the  sexual  power. 

In  this  connection  the  act  of  urination  should  be 
studied.  Seminal  vesiculitis  of  itself,  there  being  no 
inflammatory  cause  located  along  the  urinary  track, 
may,  to  an  extreme  degree,  affect  this  function.  The 
results  of  this  agent,  however,  are  not  always  alike ;  in 
fact,  they  may  be  opposite.  Thus  in  one  extreme  the 
urinary  act  may  be  stimulated  and  excited  to  such  a 
degree  that  incontinence  results,  a  rubber  urinal  having 
to  be  worn ;  and  then,  on  the  contrary,  it  may  be  in- 
hibited, sometimes  sufficiently  to  cause  temporary  re- 
tention. The  stimulating  effect  of  this  form  of  disease 
on  the  urinary  function  is  met  with  more  frequently  than 


CLINICAL  FEATURES.  99 

the  inhibitory  one.  In  many  instances,  of  course,  this 
function  is  not  in  the  least  disturbed.  Where  it  is 
stimulated  the  usual  complaint  is  that  urination  is 
urgent,  perhaps  every  hour  or  so  by  day,  although  at 
night  the  interval  is  longer  and  the  urgency  less.  On 
those  days  also  when  the  sexual  function  is  excited  and 
overtaxed  micturition  is  more  urgent.  Where  the 
function  is  inhibited  complaint  is  made  that  at  times 
urination  is  very  tardy,  and  when  it  does  occur  the 
stream  is  small,  with  no  force,  or  the  urine  comes  drop 
by  drop  or  in  little  jets.  During  the  height  of  such 
attacks  it  may  not  come  at  all  for  several  hours,  a  tight 
muscular  spasm  persisting.  When  these  attacks  pass 
off  the  stream  is  usually  satisfactory.  The  attack  is 
generally  associated  with  sexual  excitement.  In  a  case 
which  will  be  related  it  occurred  as  a  regular  thing  every 
morning,  the  individual  in  question  having  great  dif- 
ficulty for  two  or  three  hours  each  morning  after  rising 
in  voiding  his  urine,  a  hot  sitz-bath  often  being  neces- 
sary. At  other  times  during  the  day  the  stream  was 
usually  all  right  and  of  large  calibre.  The  reason  the 
author  has  for  ascribing  to  this  form  of  seminal  vesi- 
culitis functional  disturbances  in  micturition,  such  as 
have  been  described,  is  that  in  very  numerous  instances 
where  these  disturbances  have  existed,  associated  with 
subacute  or  chronic  vesiculitis,  a  cure  of  the  vesiculitis 
has  been  accompanied  by  a  spontaneous  cure  of  the 
symptoms  of  urinary  disturbance,  previous  attempts  to 
cure  them  by  the  employment  of  various  other  means 
having  wholly  failed. 

Persistent  urethral  discharges,  if  not  s}rmptomatic  of 
subacute  or  chronic  vesiculitis,  are  at  times  dependent 
on  inflammations  of  those  parts.  Such  urethral  dis- 
charges are  not  rare,  and  are  of  much  importance.     The 


100  MALE  SEXUAL  ORGANS. 

author  first  called  attention  to  them  in  an  article  on 
"  Seminal  Vesiculitis,"  Journal  of  Cutaneous  and  Genito- 
urinary Diseases,  New  York,  September,  1893  ;  and  the 
next  year,  in  the  June  and  July,  1894,  numbers  of  the 
same  journal,  he  published  an  extended  study  of  the 
subject,  under  the  heading  "Persistent  Urethral  Dis- 
charges Dependent  on  Subacute  or  Chronic  Seminal 
Vesiculitis."  In  order  to  give  the  reader  an  idea  of  this 
subject  it  has  seemed  well  to  quote  here  the  introductory 
portion  of  the  last  article,  reference  to  which  has  just 
been  made. 

"  Formerly,  oftener  than  at  present,  it  was  customary 
in  medical  literature  to  find  mention  made  of  a  class  of 
urethral  discharges  which  were  so  rebellious  under  all 
known  and  approved  forms  of  treatment  that  the  most 
efficacious  plan  seemed  to  be  to  leave  them  alone  to 
recover  as  best  they  could.  Many  such  cases  would 
finally  get  well  of  themselves,  but  in  the  great  majority 
of  these  instances  the  person  afflicted  would  be  positive 
that  something  or  other  which  he  had  done,  generally  in 
desperation,  had  cured  him. 

"  In  a  respectable  percentage  of  these  individuals  the 
extraordinary  alleged  curative  agency  would  be  sexual 
or  alcoholic  excess,  or,  and  as  very  frequently  happened, 
a  combination  of  the  two.  Since  the  introduction  of 
deep  urethral  instillations  and  of  the  electrical  illumina- 
tion of  the  urethra  through  the  endoscope,  permitting 
topical  applications  to  be  made,  cases  of  so-called  in- 
curable urethral  discharges  have  wonderfully  diminished; 
but  still  a  goodly  number  exist,  as  evidenced  by  the 
many  chronic  cases  one  sees  which  have  been  the  pro- 
fessional rounds  without  relief. 

"  I  flatter  myself  that  I  have  been  able  to  cure,  at 
least   apparently,  and  as  thoroughly  as  one  can   ever 


CLINICAL  FEATURES.  101 

claim  to  cure  a  chronic  urethral  discharge,  a  certain 
number  of  these  cases,  which  at  my  own  and  at  the 
hands  of  others  had  resisted  all  the  usual  forms  of 
treatment. 

"  In  treating  a  number  of  them  I  was  aided  by  the 
valuable  advice  and  co-operation  of  Dr.  Keyes,  and  it 
was  from  him  originally  that  I  obtained  the  ideas  which 
I  have  endeavored  to  develop.  A  consideration  and 
classification  of  these  cases,  their  histories,  more  or  less 
minute  according  to  the  points  of  interest  presented, 
together  with  some  comments,  are  the  objects  of  this 
paper. 

'*  During  my  earlier  investigations  with  reference  to 
vesiculitis,  usually  undertaken  in  the  cases  of  indi- 
viduals who  presented  symptoms  indicating  a  disturb- 
ance of  the  sexual  functions  (see  article  on  '  Seminal 
Vesiculitis'  in  the  September,  1893,  number  of  the 
Journal  of  Cutaneous  and  Genito- Urinary  Diseases),  I 
was  impressed  with  the  fact  that  in  a  certain  percentage 
there  coexisted  a  urethral  discharge,  oftentimes  some- 
what intermittent  in  character,  generally  scanty  in 
amount,  although  occasionally  profuse.  Inquiry  dis- 
closed the  fact  that  a  number  of  these  individuals  had 
already  sought  treatment  for  these  discharges,  almost 
invariably  without  success. 

"As  the  vesicles  in  these  cases  presented  the  chief 
focus  of  disturbance  all  treatment  was  directed  toward 
them,  little  or  no  attention  being  paid  at  the  time  to  the 
discharge.  As,  however,  the  vesicles  got  better  it  was 
observed  that  the  discharge  oftentimes  also  disappeared. 
These  facts,  together  with  the  instances  already  alluded 
to,  a  number  of  which  had  come  under  my  personal 
observation,  where  patients  tiring  of  a  tedious  and  ap- 
parently  futile    treatment    for   chronic    discharge,    had 


102  MALE  SEXUAL  ORGANS. 

broken  the  rules  laid  down  by  their  medical  advisers  and 
indulged  freely  in  sexual  intercourse,  resulting  in  the 
cure  of  their  complaint,  led  me  to  investigate  the  con- 
dition of  the  seminal  vesicles  in  all  cases  where  a  dis- 
charge had  proved  itself  rebellious  to  the  ordinary 
modes  of  treatment,  even  though  there  were  apparently 
no  coexisting"  sexual  derangements. 

"  Within  the  last  two  years,  during  which  time  I  have 
been  actively  investigating  this  subject,  I  have  seen 
quite  a  number  of  cases  which  apparently  were  of  the 
class  under  consideration ;  but  in  this  article  it  has 
seemed  best  to  notice  only  such  of  them  as  remained 
under  my  personal  supervision  for  a  considerable  in- 
terval, and  concerning  the  final  outcome  of  which  I  am 
well  acquainted,  all  transient  cases  and  those  simply 
seeking  a  diagnosis  with  instructions  being  discarded. 
The  cases  thus  left  for  consideration  number  twenty-two. 
Of  these,  seven  were  evidently  tubercular  in  character, 
and  will  be  considered  last  of  all  by  themselves,  the 
fifteen  representing  simple  inflammatory  conditions 
coining  first. 

"  In  most  of  these  fifteen  cases  the  origin  of  the  in- 
flammation was  gonorrhoea].  In  some  of  them  that 
disease  was  the  immediate  cause  of  the  vesiculitis, 
though  commonly  it  was  found  to  be  the  cause  more  or 
less  remote.  All  but  one  of  the  fifteen  acknowledged 
having  had  gonorrhoea  at  some  time  or  other,  although 
a  number  of  those  admitting  a  former  clap  did  not 
themselves  ascribe  their  existing  trouble  to  that  source. 

"  In  twelve  of  the  fifteen  cases,  as  the  result  of  treat- 
ment, all  signs  of  discharge  have  disappeared,  although 
in  several  of  these  twelve  cases  some  signs  of  vesicu- 
litis still  exist,  it  having  been  observed  that  ordinarily 
the  discharge  ceases  before  complete  resolution  in  the 


CLINICAL  IEATURES.  103 

vesicles  has  taken  place.  On  this  account  some  patients 
consider  themselves  cured  when  the  discharge  stops,  and 
consequently  become  careless  or  neglectful  of  further 
treatment  directed  toward  the  final  cure  of  the  vesicu- 
litis. Of  the  remaining  three  cases,  all  very  chronic  in 
character,  one  is  slowly  but  steadily  improving ;  one  is 
irregular  in  attendance,  easily  discouraged,  and,  although 
somewhat  better,  is  not  relieved ;  and  one  an  elderly 
gentlemen,  with  considerable  accompanying  chronic 
prostatic  hypertrophy,  showed  no  signs  of  improvement 
after  numerous  treatments." 

In  many  of  these  cases,  where  the  discharge  was 
promptly  and  permanently  cured  with  the  cure  of  the 
vesiculitis,  it  had  persisted  for  years,  rebellious  to  all 
forms  of  treatment  directed  toward  the  urethra  and 
bladder.  An  important  point  also  with  many  of  these 
cases  was  that  although  a  discharge  was  present,  still  a 
careful  inspection  and  examination  of  the  urethra  failed 
to  reveal  any  inflammatory  lesion,  such  as  one  would 
expect  to  find  as  a  cause  for  chronic  discharge.  If, 
therefore,  a  urethral  discharge  persists,  associated  with 
symptoms  of  vesiculitis,  such  as  we  have  considered,  or 
if  it  persists,  there  being  apparently  no  urethral  lesion, 
even  if  other  symptoms  of  vesiculitis  are  not  prominent, 
seminal  vesiculitis  should  be  suspected  as  a  cause  there- 
for. In  this  connection,  however,  it  has  seemed  well  to 
quote  again  from  the  author's  article  in  order  to  guard 
against  conclusions  in  this  particular  which  may  have 
been  too  hastily  or  too  superficially  drawn. 

"  It  is  quite  possible  that  readers  of  this  article,  after 
considering  the  cases  reported,  in  which  the  urethral 
discharge  was  seemingly  dependent  on  the  associated 
vesiculitis,  may  infer  that  such  a  discharge  is  one  of  the 
cardinal  symptoms  to  be  looked  for  in  diagnosticating 


104  MALE  SEXUAL  ORGANS. 

this  disease.  This  idea  is  to  be  discouraged,  not  only 
because  it  is  very  inaccurate,  since  in  a  great  many  cases 
of  vesiculitis  there  is  no  discharge,  but  also  because  it 
might  lead  those  who  are  inclined  to  be  superficial  and 
to  jump  at  conclusions  to  neglect  the  study  of  the 
urethra,  the  common  seat  of  the  lesion  causing  a  dis- 
charge, together  with  other  possible  sources.  We  have 
all  seen  illustrated  this  tendency  to  jump  at  conclusions 
in  this  same  matter  of  persistent  urethral  discharges,  as 
the  result  of  Dr.  Otis's  writings  on  stricture  of  large 
calibre.  These  ideas,  good  in  themselves,  and  valuable 
in  the  right  place,  were  so  perverted  that  it  became  the 
routine  practice  with  many  to  cut  freely  the  anterior 
urethra,  not  only  in  all  cases  where  there  was  a  chronic 
discharge,  but  also  oftentimes  even  for  pus  in  the  urine, 
no  attempt  apparently  having  been  made  to  trace  the 
source  of  the  pus,  which  in  a  number  of  cases  I  have  in 
mind  was  of  pelvic  origin." 

Variations  in  the  urine  may  depend  on  subacute  or 
chronic  vesiculitis,  and  consequently  may  be  symptom- 
atic more  or  less  directly  of  those  conditions.  In  the 
chapter  on  pathology  attention  has  already  been  called 
to  the  floating  shreds  of  glairy,  sticky  material  often 
found  in  the  urine  of  individuals  so  affected,  and  which 
under  the  microscope  prove  to  be  made  up  of  vesicular 
fluid,  sympexions,  spermatoza,  etc.  In  a  certain  per- 
centage of  the  cases  where  urethral  discharges  depen- 
dent on  a  vesiculitis  have  existed,  more  or  less  free  pus 
has  also  been  noted  in  the  urine.  Observation  in  a 
number  of  these  cases  has  shown  that  this  pus  disap- 
peared the  same  as  the  discharge  when  a  cure  of  the 
vesiculitis  was  effected.  The  point,  however,  of  chief 
importance  in  this  connection  is  that  at  times  the  pres- 
ence of  bacteria  in  the  urine  is  dependent  on  a  chronic 


CLINICAL  FEATURES.  105 

vesiculitis,  which  is  itself  complicated  by  germ-infection. 
We  have  already,  in  studying  pathology,  considered  this 
complication  of  germ-infection  in  connection  with  chronic 
vesiculitis.  In  such  bacterial  urines  the  inflamed  vesicle 
may  be  the  source  of  the  supply,  the  germs  entering  the 
bladder  either  directly  through  the  intervening  tissues, 
penetrating  its  walls,  as  Eeymond  has  shown  us  they 
can  do,  or  by  the  way  of  the  ejaculatory  ducts.  These 
urines,  provided  no  pathological  factors  exist  in  con- 
nection with  the  bladder,  can  be  freed  from  bacteria  by 
eliminating-  the  neighboring  focus  of  infection,  which 
result  can  be  accomplished  by  curing  the  vesiculitis,  or 
by  ridding  it  of  its  bacterial  complication.  An  illus- 
trative instance  or  two  of  this  will  be  cited  in  the 
chapter  devoted  to  cases.  A  few  special  remarks  on  the 
subject,  however,  in  this  connection  will  not  be  out  of 
place.  If  bacteria  persist  in  the  urine  of  an  individual 
in  whose  case  the  factors  favorable  to  germ-propagation 
in  the  bladder  are  absent,  such  as  defective  drainage 
resulting  from  stricture,  prostatic  enlargement,  vesical 
atony,  etc.,  and  cystitis  in  its  various  forms,  then  an 
outside  focus  of  propagation  should  be  looked  for  to 
account  for  the  source  of  the  germ-supply.  Such  a  focus 
is,  in  the  majority  of  these  instances,  situated  in  the 
pelvis  of  the  kidney.  In  a  minority  of  them,  however, 
it  is  in  the  vicinity  of  the  bladder,  generally  from  the 
seminal  vesicle  or  from  a  perivesicular  abscess,  the 
cavity  of  which  may  or  may  not  communicate  directly 
with  the  bladder  by  means  of  a  sinus.  That  such  a 
focus  of  infection  is  at  times  in  the  vesicle  has  been 
proved  by  the  author  in  a  number  of  instances  in  the 
following  manner:  In  a  representative  case  the  con- 
tents of  an  infected  vesicle  have,  by  rectal  digital  ma- 
nipulation, been  pressed  out  along  the  ejaculatory  duct. 


106  MALE  SEXUAL  ORGANS. 

The  seminal  material  which  has  dripped  from  the  meatus 
as  the  direct  result  of  the  manipulation  before  the  act 
of  urination  has  been  found  to  contain  great  quantities 
of  bacteria  similiar  to  those  existing  in  the  urine,  and 
the  urine  then  passed  immediately  after  this  has  been 
found  to  be  loaded  very  much  more  than  usual  with  the 
bacteria.  After  a  time,  as  the  result  of  such  manipula- 
tions undertaken  at  proper  intervals,  the  vesicular  focus 
of  germ-growth  has  been  eliminated.  Coincidently  with 
this  elimination  of  germs  from  the  vesicle  it  has  been 
discovered  that  similar  germs  no  longer  exist  in  the 
urine.  In  such  an  instance  these  experiments  conclu- 
sively show  the  source  of  the  bladder  infection  to  be 
from  the  vesicle,  and  eliminate  the  kidney  pelvis  from 
any  participation  in  the  matter.  Krogius,  of  Helsing- 
fors  (Annal.  des  Malad.  des  Organes  Genito-Urinaires, 
Paris,  September,  1894),  records  a  number  of  cases 
where  in  the  urine  freshly  voided  bacteria  in  large 
amounts  were  always  to  be  found,  unassociated,  how- 
ever, with  any  discoverable  inflammatory  processes  of 
the  urinary  tract.  For  the  existence  of  such  a  state 
of  affairs,  when  occurring  in  the  male,  he  could  offer  no 
valid  reason.  To  the  author,  however,  it  seems  probable 
that  an  infected  and  inflamed  seminal  vesicle  was  the 
source  of  the  germs  in  most,  if  not  all,  of  these  cases. 

Albumin  in  small  amount,  unassociated  with  pus, 
may  also  be  present  in  the  urine,  dependent  on  an  exist- 
ing seminal  vesiculitis.  That  such  is  a  fact  can  be 
demonstrated  by  curing  the  vesiculitis  in  a  case  of  this 
nature,  in  which  event  the  trace  of  albumin  will  disap- 
pear. A  small  amount  of  albumin  is  especially  apt  to 
occur  in  those  cases  of  vesiculitis,  such  as  have  just 
been  described,  in  which  the  complication  of  bladder 
germ-infection  occurs.     For  this  reason  they  are  liable 


CLINICAL  FEATURES.  107 

to  be  wrongly  diagnosticated  as  cases  of  pyelitis.  After 
sexual  excitement  or  exercise  the  amount  of  albumin 
may  be  somewhat  increased. 

Blood  may  appear  in  the  urine  or  associated  with  an 
urethral  discharge,  its  presence  being  apparently  depen- 
dent on  an  existing  chronic  seminal  vesiculitis.  The 
author  has  seen  one  such  instance.  In  this  case  there 
were  bloody  emissions,  and  bleeding  at  the  end  of  the 
urinary  act  was  frequent.  There  was  present  also  a 
constant  urethral  discharge,  which  was  at  times  tinged 
with  blood.  All  attempts  to  control  this  bleeding  by 
methods  directed  toward  the  urethra  or  bladder  had 
failed.  The  cure  of  a  chronically  inflamed  vesicle  re- 
sulted in  a  permanent  cure  of  the  bleeding,  as  well  as 
of  the  discharge. 

A  marked  tendency  to  phosphatic  turbidity  of  the 
urine  is  at  times  noticeable  in  those  suffering  from 
chronic  vesicular  disease,  due  probably  in  great  measure 
to  nervous  derangements  resulting  from  it.  The  pres- 
ence of  crystals  of  calcic  oxalate  may  also  occasionally 
be  accounted  for  in  the  same  manner.  When  such  is 
the  case,  these  disturbances  in  connection  with  the  urine 
are  liable  gradually  to  disappear  as  the  cause  for  the 
nervous  derangements  is  removed. 

Indirect  Symptoms.  These  symptoms  have  already 
been  defined  at  the  opening  of  the  chapter.  In  describ- 
ing them  the  neurotic  disturbances  will  be  considered 
first,  the  mental  ones  afterwrard.  As  has  been  said, 
neurotic  disturbances  of  this  class  generally  bear  no 
apparent  connection  with  vesicular  disease ;  but  that 
they  are  dependent  on  it  is  shown  by  the  fact  that  they 
disappear  as  resolution  takes  place  in  the  vesicles. 
These  disturbances  are  very  varied  and  peculiar,  and, 
although  the  attempt  will  here  be  made  to  enumerate 


108  MALE  SEXUAL  ORGANS. 

such  of  them  as  have  come  to  notice,  still  the  enumera- 
tion will  probably  be  imperfect,  as  further  studies  in 
this  direction  may  demonstrate.  Severe  headaches  may 
be  complained  of.  In  these  cases  the  patient  frequently 
locates  the  pain  in  the  region  of  the  temples  or  in  the 
occiput,  and  describes  it  as  very  sharp  in  character ;  or 
it  may  be  general,  in  which  instance  it  is  liable  to  be 
described  as  dull  or  throbbing.  These  headaches  will 
usually  be  found  to  be  occasioned  or  intensified  by 
sexual  excitement  or  strain,  emissions,  and  sometimes 
even  by  the  sight  or  thought  of  an  attractive  woman. 
Sharp  attacks  of  pain  in  the  epigastrium  may  be  a 
feature.  Such  pains  are  probably  due  to  neuralgia  of 
the  cceliac  plexus.  A  case  of  this  description  has  come 
to  notice  where  the  individual,  owing  to  such  attacks, 
was  treated  for  over  a  year  for  intestinal  colic,  supposed 
to  be  due  to  functional  bowel  derangements.  Extensive 
treatment  in  that  direction,  however,  did  him  no  good. 
After  a  careful  examination  no  other  evidences  of  bowel 
derangement,  aside  from  intermittent  attacks  of  epi- 
gastric pain,  being  discovered,  attention  was  directed  to 
other  sources  in  search  for  a  cause.  As  a  result  of 
questioning  he  was  found  to  be  suffering  from  symptoms 
pointing  to  the  vesicles.  Although  married,  he  was 
troubled  with  seminal  emissions,  his  sexual  desire  was 
weak,  and  his  power  feeble,  the  act  of  coitus  being  ex- 
hausting. It  was  also  found  that  the  attacks  of  sup- 
posed colic  generally  followed  sexual  excitement  or 
action.  Vesiculitis  was  discovered  and  relieved,  since 
which  time  there  have  been  no  more  attacks  of  epigastric 
pain.  A  case  of  vesiculitis  was  observed  where  there 
had  coexisted  with  numerous  well-defined  symptoms  of 
that  disease  a  peculiar  buzzing  or  ringing  sensation  in 
connection  apparently  with   the  ears.     This   sensation 


CLINICAL  FEATURES.  109 

had  really  been  the  feature  of  the  case,  advice  having 
been  sought  regarding  it  from  several  aurists  without 
apparent  benefit.  As  the  individual  wished  to  get 
married,  and  was  fearful  of  doing  do,  doubting  his 
sexual  capacity,  advice  in  that  connection  was  sought. 
Vesiculitis  was  discovered  and  cured,  one  result  being 
that  the  ear  disturbance  promptly  and  permanently  dis- 
appeared. Among  similar  disturbances  which  have 
been  observed  to  disappear  permanently  with  a  cure  of 
the  existing  vesiculitis  are  feelings  of  numbness  in  con- 
nection with  the  extremities,  hot  sensations,  at  times 
alternating  with  cold  ones,  generally  of  the  extremities, 
sometimes  in  connection  with  the  body,  in  which  case 
they  may  be  located  in  the  spinal  region ;  hyperesthesia 
or  anaesthesia  of  varying  degrees  and  situations,  some- 
times complained  of  in  connection  with  one  side  of  the 
body,  thus  making  the  individual  fearful  of  impending 
paralysis ;  sensations  in  various  parts,  such  that  often- 
times the  sufferer  becomes  suspicious  of  cancer,  etc. 
In  fact,  it  may  be  said  that  all  the  symptoms  which  it 
is  customary  to  associate  with  hysteria  may  be  indirect 
neurotic  symptoms  due  to  an  existing  seminal  vesicu- 
litis. From  this  statement,  however,  it  must  not  be 
assumed  that  hysteria  in  the  male  is  necessarily  depen- 
dent on  disease  of  the  vesicles,  for  in  many  instances, 
and  probably  in  the  majority  of  them,  such  is  not  the 
case,  the  vesicles  being  pathologically  sound. 

Mental  disturbances  are  often  a  feature ;  in  fact,  as  has 
been  dwelt  upon  in  the  introductory  chapter,  it  has 
hitherto  been  customary  in  such  cases  to  regard  the 
mind  as  the  seat  of  trouble,  the  idea  that  pathological 
or  physiological  factors  in  connection  with  the  sexual 
apparatus  could  be  accountable  having  not  even  been 
thought  of,  or,  at  most,  discarded  as  of  no  importance. 


110  MALE  SEXUAL   ORGANS. 

That  such  is  so,  reference  is  made  to  the  recent  article 
on  sexual  neurasthenia  by  Guyon  (A.nnal.  des  Malad. 
des  Organ.  Genito-Urinaires,  Paris,  November,  1894),  a 
geni  to-urinary  authority  of  great  eminence,  in  which, 
although  it  is  admitted  that  a  gonorrhoea  often  precedes 
sexual  neurasthenia,  and  that,  should  a  digital  rectal 
exploration  be  attempted  in  one  of  these  cases,  great 
tenderness  would  probably  be  complained  of  in  the 
vesicular  region,  yet  it  is  asserted  that  in  these  cases 
there  exists  no  pathological  cause,  local  or  otherwise, 
for  the  symptoms,  but  that  functional  disturbances  in 
connection  with  the  nerve-centres  are  accountable  for, 
and,  in  fact,  are  the  source  of,  all  existing  disturbances. 
The  author,  however,  is  certain  that  had  Guyon  investi- 
gated the  tender  vesicular  area,  revealed  by  digital 
exploration  of  the  rectum,  especially  in  those  cases 
where  there  had  been  a  preceding  gonorrhoea,  such  as 
he  mentions,  pathological  changes  of  an  inflammatory 
nature  would  have  been  discovered,  which  would  have 
necessitated  a  modification  in  his  statement  that  no 
pathological  conditions  coexisted;  and  the  author  feels 
confident  that  had  this  eminent  surgeon  directed  his 
treatment  toward  the  vesicles,  and  had  he  cured  them, 
his  opinion  regarding  the  origin  of  the  existing  symp- 
toms would  also  have  been  modified,  the  vesicles  rather 
than  the  nerve-centres  being  held  to  be  the  source 
largely,  if  not  wholly,  of  all  trouble. 

These  mental  symptoms  are  melancholy  in  character. 
In  the  lighter  grades  complaint  is  frequent  of  a  feeling 
of  mental  lassitude,  of  a  disinclination  to  mental  appli- 
cation, and  of  a  difficulty  in  the  concentration  of  thought. 
After  moderate  mental  application,  or  after  acts  which 
require  an  exhibition  of  skill,  nerve,  or  good  judgment, 
there  is  often  complained  of  a  feeling  of  undue  prostra- 


CLINICAL  FEATURES.  HI 

tion  ;  the  hand  trembles,  and  there  is  a  cold  perspiration, 
associated  with  sensations  of  exhaustion,  on  making 
further  attempts,  the  like  of  which  would  formerly  have 
been  easy  of  accomplishment.  The  mind  in  some  in- 
stances is  not  clear ;  there  may  be  a  reversion  of  thought 
more  or  less  frequent  to  sexual  subjects.  Among  the 
subjects  of  this  nature  on  which  the  mind  often  ponders 
are  fears  of  impotency.  The  sexual  powers  of  by-gone 
days  are  compared  with  those  of  the  present,  or  what 
others  have  said  regarding  their  own  powers,  or  the 
remarks  of  lewd  women,  generally  in  derision,  are 
treasured  up,  resulting  in  an  augmentation  of  these 
fears.  From  a  fear  of  being  laughed  at,  owing  to  their 
supposed  weakness,  individuals  of  this  class  may  become 
very  shy  regarding  women.  When  this  is  the  case, 
their  fears  of  impotency  are  liable  to  be  confirmed,  at 
least  in  their  own  minds,  for  when  they,  possessed  of 
such  feelings,  attempt  intercourse,  and  especially  with  a 
stranger,  the  act  is  a  failure,  either  because  sufficient 
erection  does  not  result,  or  because  ejaculation  is  too 
precipitate.  Closely  allied  to  fears  of  impotency  are 
fears  regarding  marriage.  These  individuals  often  en- 
gage themselves  to  marry,  having  at  first  thought  little 
of  their  sexual  capacity ;  then  later,  their  sexual  dis- 
turbances being  intensified  by  the  engaged  state,  they 
begin  to  become  fearful  regarding  their  ability  to  con- 
summate the  marital  act.  From  this  a  mental  brooding 
and  melancholy  may  result.  At  other  times  the  pain 
and  reflex  sensations  and  symptoms  attendant  on  a 
seminal  vesiculitis,  by  their  constancy  and  persistency, 
may  in  like  manner  affect  the  mind.  In  such  instances, 
at  first  sight  the  mental  derangement  may  not  appear  to 
bear  any  relation  to  the  sexual  organs,  since  the  cause 
and  effect  are  not  in  direct  connection.     A  little  study 


112  MALE  SEXUAL  ORGANS. 

or  a  cure  of  the  vesiculitis  will,  however,  demonstrate 
the  relationship.  These  melancholy  tendencies  do  not 
affect  all  dispositions  alike.  Many  naturally  vivacious 
and  lively  throw  off  their  despondent  feelings  by  stimu- 
lants and  excitement.  With  such,  however,  the  mental 
suffering  when  it  does  occur  is  very  keen.  A  patient 
of  this  class,  who  had  been  a  great  sufferer  from  a  severe 
grade  of  vesiculitis,  and  who  is  at  the  present  time  so 
nearly  well  of  his  local  disease  that  he  no  longer  ex- 
periences from  it  any  disagreeable  symptoms,  states  that 
several  times  before  he  had  experienced  relief  in  his 
attacks  of  melancholy  he  had  contemplated  suicide,  and 
would  surely  have  resorted  to  that  extreme  measure  if 
he  had  thought  that  no  other  means  would  afford  him 
permanent  relief.  Others  of  the  mentally  active  class 
become  irritable  and  quick-tempered.  The  author  has 
one  extreme  case  in  mind  where  the  individual  so  af- 
fected became  so  irritable  that  he  often  resorted  to  blows 
over  trivial  matters.  This  irritability  became  so  marked 
that  business  dealings  with  him  were  impossible.  Many 
of  his  acquaintances,  according  to  his  own  admission, 
thought  him  crazy,  and  at  one  time  he  did  have  mental 
delusions  in  the  form  of  ideas  that  people  were  plotting 
against  him.  A  cure  of  all  these  symptoms,  together 
with  a  disappearance  of  the  irritability  and  a  return  to 
the  natural  disposition,  resulted  from  treatment  directed 
toward  the  vesiculitis,  mental  remedies  having  proved 
ineffectual  or  of  temporary  benefit.- 

Where  there  are  symptoms  of  mental  restlessness, 
insomnia  is  also  liable  to  be  a  prominent  feature.  It  is 
quite  common  for  individuals  suffering  from  this  form  of 
wakefulness  to  state  that  they  cannot  sleep  without  each 
evening  imbibing  freely  of  stimulants,  preferably  malt 
liquors,  as  English  ales  and  beers.    The  preference  given 


CLINICAL  FEATURES.  113 

to  malt  liquors  is  probably  due  to  the  fact  that  besides 
their  alcoholic  effect  they  have  a  local  stimulating  one 
on  the  urinary  organs. 

It  is  not  rare  for  this  class  of  individuals,  if  married 
or  living:  with  a  mistress,  to  find  themselves  consumed 
with  a  jealousy  or  with  suspicions  that  their  companions 
are  unfaithful.  On  investigation,  however,  it  is  usual  to 
find  that  there  is  no  real  foundation  for  their  suspicions, 
and  many  times  they  can  be  temporarily  apparently  rid 
of  these  vagaries  by  resorting  to  reason,  only  to  lapse 
back  to  them  again  without  justifiable  cause  in  a  short 
time. 

Some  instances  of  sexual  mental  perversion  depend 
upon  or  have  originated  in  a  seminal  vesiculitis  which 
has  been  associated  either  with  sexual  craving,  from 
which  coitus  gave  little  or  no  relief,  or  else  with  weak- 
ened sexual  desire,  which  required  in  order  to  be  aroused 
some  extraordinary  form  of  excitement.  The  fact  must 
always  be  borne  in  mind,  however,  in  this  connection 
that,  as  a  rule,  mental  sexual  perversion  is  significant  of 
a  primary  mental  degeneration,  seminal  vesiculitis  not 
coexisting ;  or,  if  it  does  coexist,  that  it  is  present  as  a 
result  of  the  perversion,  together  with  the  excesses 
dependent  upon  it ;  in  other  words,  that  it  is  generally 
secondary  to  an  existing  mental  state  rather  than  pri- 
mary to  a  non-existing  one. 

It  would  be  impracticable  to  try  to  enumerate  all  the 
curious  mental  vagaries  which  are  clinically  encountered 
dependent  indirectly  on  seminal  vesiculitis.  It  is  always 
well,  however,  to  keep  in  mind  the  seminal  vesicles  as  a 
possible  source  of  trouble  in  examining  professionally 
cases  of  sexual  neurasthenia ;  and,  in  fact,  in  order  to 
avoid  mistake  in  examining  all  cases  of  neurasthenia  in 
the  male,  the  causes  for  which  are  obscure,  even  though 


114  MALE  SEXUAL  ORGANS. 

none  of  the  direct  symptoms  such  as  have  been  studied 
are  prominently  present. 

The  severity  of  a  seminal  vesiculitis  cannot  be  appre- 
ciated by  the  severity  of  the  symptoms  which  have  been 
enumerated,  for  sometimes  light  grades  of  disease  may 
be  accompanied  by  severe  symptoms,  and  vice  versa. 
Then,  again,  seminal  vesiculitis  may  be  very  barren  of 
symptoms.  The  author  has  in  mind  a  case  where,  al- 
though marked  disease  existed  in  connection  with  one 
vesicle,  there  were  no  sexual  symptoms ;  and,  in  fact, 
no  subjective  symptoms,  aside  from  a  profuse  persistent 
urethral  discharge,  which  had  resisted  all  forms  of 
urethral  treatment,  but  which  was  permanently  cured 
by  treatment  directed  toward  the  cure  of  the  vesiculitis. 

Histories.  On  making  inquiries  into  the  histories  of 
cases  of  subacute  or  chronic  seminal  vesiculitis  it  is 
most  common  to  find  that  gonorrhoea  has  existed. 
There  may  have  been  several  attacks  of  the  disease,  or 
the  original  disease  may  have  relapsed  on  numerous 
occasions.  Then,  again,  there  may  never  have  been  but 
one  attack,  and  that  of  short  duration,  years  before,  no 
trace  of  it  ever  having  apparently  recurred.  Oftentimes 
associated  with  these  gonorrhoeas,  or  with  their  after- 
effects, there  has  been  epididymitis.  Many  patients 
when  questioned  ascribe  their  troubles  directly  to  a 
gonorrhoea,  stating  that  they  have  never  felt  really  per- 
fectly right  since  their  infection.  Others  trace  their 
seminal  troubles  to  the  after-effects  of  gonorrhoea,  such 
as  cystitis,  posterior  urethritis,  stricture,  etc.,  or  to  the 
means  employed  to  effect  a  cure  of  such  conditions. 
The  means  employed,  to  which  reference  is  usual,  are 
sounds,  strong,  deep  injections,  and  strong  vesical 
lavage.  Should,  however,  patients  making  such  com- 
plaint be  questioned  closely  it  will  almost  always  be 


CLINICAL  FEATURES.  115 

found  that  symptoms  of  seminal  vesiculitis  had  already 
previously  existed,  mild,  perhaps,  and  consequently 
attracting  little  attention ;  and  that  the  modes  of  treat- 
ment enumerated,  having  been  injudiciously  applied, 
had  resulted  in  lighting  up  these  symptoms  afresh  and 
in  augmenting  their  severity,  besides,  in  some  instances, 
introducing  new  ones  such  as  had  not  hitherto  appeared. 
Combined  with  the  history  of  previous  gonorrhoea  the 
admission  of  habits  of  sexual  and  alcoholic  excesses  are 
frequent.  Of  these  habits  those  of  sexual  excess  are 
the  more  causative  of  trouble ;  in  fact,  sexual  excess 
may  be  the  only  apparent  cause  for  seminal  vesiculitis, 
a  gonorrhoea  never  having  existed.  Such  excesses  in 
adults,  say  in  men  of  twenty-five  years  or  over,  com- 
paratively rarely  affect  the  vesicles.  It  is  in  the  growing 
youth,  however,  where  the  bad  effects  are  most  aroused. 
This  is  especially  seen  in  cases  where  boys  have  been 
made  use  of  by  grown  women,  who  have  taxed  their 
young  sexual  powers  to  the  utmost  over  considerable 
periods  of  time.  A  gentleman,  a  very  aggravated  case 
of  vesicular  disease,  and  one  who  had  never  been  infected 
by  gonorrhoea,  told  the  author  that  he  attributed  the 
commencement  of  his  trouble  to  the  sexual  intercourse 
in  which  he  had  indulged  at  the  age  of  twelve  years. 
His  partners  consisted  of  five  sisters,  next-door  neigh- 
bors, averaging  considerably  older  than  himself,  who 
sought  pleasure  in  turn.  Numerous  other  similar  ex- 
amples, not  quite  so  aggravated  perhaps  as  this,  could 
be  enumerated.  This  cause  seems  of  sufficient  impor- 
tance and  frequency  to  make  it  desirable  for  parents  to 
be  mindful  of  it,  in  order  that  their  boys  may  be  afforded 
some  protection. 

Alcoholic  excess  rarely,  if  ever,  appears  by  itself  as  a 
cause.     Unnatural  sexual  practices,  such  as  masturba- 


116  MALE  SEXUAL  ORGANS. 

tion  to  any  excess  and  the  various  methods  adopted  by 
libertines  in  order  to  produce  the  keenest  sexual  sensa- 
tions by  acts  tending  to  overexcite  the  sexual  centre 
or  to  keep  it  excited  for  a  prolonged  interval,  are  causa- 
tive factors  of  importance  in  the  history  of  these  cases. 
The  practices  of  libertines  are  probably  in  themselves 
sufficient  in  most  instances,  where  they  have  been  in- 
dulged in  excessively  and  for  considerable  periods,  to 
cause  a  vesiculitis,  aside  from  the  fact  that  gonorrhoea 
of  an  earlier  date  has  coexisted.  In  most  of  them, 
however,  there  has  been  a  former  gonorrhoea ;  and  this 
history  should  be  expected,  even  though  the  early  clap 
be  no  special  factor  in  the  existing  vesiculitis,  since 
individuals  of  this  class,  owing  to  almost  unlimited 
exposures  during  their  careers,  rarely  escape  from  having 
first  and  last  all  forms  of  venereal  disease. 

Abstinence  from  sexual  exercise  may,  under  certain 
conditions,  appear  as  the  sole  cause  for  seminal  vesicu- 
litis. The  local  inflammation  when  of  this  nature  is 
usually  of  a  light  grade,  though  the  subjective  symp- 
toms, especially  the  mental  ones,  are  apt  to  be  severe. 
Among  the  cases  illustrative  of  this  condition  it  is  cus- 
tomary to  find  those  of  young  or  middle-aged  men,  who 
have  from  six  months  to  several  years  previously  lost 
their  sexual  companions,  since  which  time,  generally  from 
conscientious  scruples  or  sorrow,  and  occasionally  from 
lack  of  opportunity  or  medical  prohibition,  there  has 
been  a  sudden  and  entire  abstinence  from  the  customary 
habit  of  sexual  intercourse.  Somewhat  similar  to  these 
cases,  though  less  common,  are  those  of  bachelors,  gen- 
erally in  the  neighborhood  of  thirty  to  thirty-five  years 
old,  who,  though  possessed  of  strong  sexual  inclinations, 
have  always,  owing  to  conscientious  scruples  or  to  their 
calling,  by  the  exercise  of  will-power,  kept  these  pas- 


CLINICAL  FEATURES.  117 

sions  in  abeyance,  and  have  never  consequently  at- 
tempted sexual  intercourse. 

Another  variety  of  this  class  are  those  who  can  be 
grouped  as  sexual  triflers.  These  individuals,  though 
always  occupied  with  women  or  young  girls,  never  do 
more  than  trine  with  them,  and  never  visit  prostitutes. 
Nine  chances  out  of  ten,  however,  such  persons  are 
persistent  masturbators,  and  it  is  to  that  practice  rather 
than  to  abstinence  that  their  vesiculitis  should  be  gen- 
erally attributed. 

Abuses  on  the  part  of  the  male  in  connection  with 
the  natural  sexual  act,  undertaken  in  order  to  avoid 
conception,  are  found  to  be  causes  quite  frequently  for 
vesiculitis,  or  for  aggravating  an  existing  inflammation 
of  this  character.  Chief  among  these  are  premature 
withdrawal  and  the  wearing  of  tight  elastic  rubber 
condoms,  the  rim  of  which  consists  of  a  rubber  ring 
which  encircles  the  base  or  middle  portion  of  the  penis, 
thus  offering  resistance  to  the  ejaculatory  act. 

Rarely  cases  representing  light  grades  of  vesiculitis 
are  observed  where  from  the  histories  the  only  cause  to 
be  found  consists  of  an  apparent  loss  of  nerve-tone  to 
the  muscular  apparatus  employed  in  the  act  of  ejacula- 
tion. Instances  illustrative  of  this  condition  may  be 
seen  associated  with  structural  or  inflammatory  diseases 
of  the  spine  and  brain,  and  sometimes  with  any  chronic 
debilitating  disease.  In  these  cases,  however,  a  slight 
derangement  of  the  vesicles  is  of  little  moment  in  com- 
parison  with  the  chief  disease,  and  so  deservedly  attracts 
little  attention.  But  in  some  instances  the  lack  of  nerve- 
tone  is  due  to  general  nervous  fatigue  and  exhaustion, 
and  in  these  the  resulting  vesiculitis,  by  reason  of  its 
symptoms,  in  turn  reacts  on  the  nerves.  Then  the 
mental  fret  so  caused  aggravates  the  original  state  and 


118  MALE  SEXUAL  ORGANS. 

serves  as  a  bar  to  convalescence,  even  though  rest  be 
attempted.  It  is  in  these  latter  cases  that  the  vesicu- 
litis is  important,  as  a  little  attention  paid  to  it  will  tend, 
in  connection  with  mental  rest,  to  hurry  a  cure,  which 
otherwise  would  bid  fair  to  be  tedious. 

In  reviewing  the  histories  of  cases,  inflammatory  con- 
ditions being  excluded,  it  can  be  stated  in  a  general  way 
that  anything  injurious  to  muscular  tissue-development 
will  injure  the  muscular  apparatus  employed  in  the  act 
of  ejaculation  exactly  as  when  applied  to  the  muscular 
structure  of  other  parts.  Thus,  if  the  muscles  of  these 
parts  are  worked  too  hard  and  abused,  the  tone  and  con- 
tractile power  are  diminished.  On  the  other  hand,  if  they 
are  overstretched,  as  when  the  cavity  of  the  vesicle  is 
much  distended  or  never  called  into  action,  they  event- 
ually become  weak  and  flabby.  If  they  are  badly 
nourished,  as  the  result  of  general  conditions,  such  as 
poor  circulation,  defective  oxygenation  of  the  blood,  or 
impaired  nerve-action,  these  muscles,  in  common  with 
those  of  other  parts,  become  weak  and  capable  of  little 
executive  action. 

Physical  Sights  Resulting,  from  Rectal  Ex- 
ploration. These  signs  are  of  the  greatest  impor- 
tance, as  it  is  by  them  that  the  existence  and  extent  of 
disease  are  verified,  the  presence  of  which  was  suspected 
from  the  associated  symptoms  and  histories.  It  is  well, 
however,  to  state  here  that  the  forefinger,  the  member 
employed  in  this  exploration,  must  be  carefully  educated 
in  this  particular,  in  order  to  enable  it  to  draw  definite 
conclusions,  otherwise  the  aid  derived  from  it  is  of  as 
little  value  as  the  aid  from  an  untrained  eye  would  be 
in  attempting  to  draw  conclusions  from  the  use  of  the 
ophthalmoscope  or  the  cystocope.  In  accomplishing 
this   education   extensive   practice   is   necessary — first, 


CLINICAL  FEATURES.  119 

in  order  to  render  the  linger  familiar  with  all  the  phases 
encountered  in  normal  conditions  of  the  parts,  and, 
secondly,  in  order  to  enable  it  not  only  to  detect  ab- 
normal conditions  when  present,  but  also  to  distinguish 
between  their  different  grades,  such  as  the  consideration 
of  the  pathology  of  the  part  has  shown  to  exist.  The 
approved  technique  to  be  employed  in  making  this 
digital  exploration  will  be  fully  considered  in  the  chapter 
devoted  to  treatment.  In  some  individuals,  especially 
in  those  inclined  to  be  fat,  where  the  vesicles  are  im- 
bedded in  a  cushion  of  adipose  tissue,  it  may  be  impos- 
sible for  the  expert  finger  to  map  them  out  if  they  be 
normal ;  but  in  most  instances  the  outline  of  the  normal 
sac,  though  oftentimes  indistinct,  can  nevertheless  be 
definitely  located.  In  making  an  exploration  of  this 
nature  the  first  thing  to  be  done  is  carefully  to  note  the 
condition  of  the  prostate.  This  gland  may  be  atrophied 
or  hypertrophied.  Atrophic  conditions  are  rare  and  are 
of  comparatively  little  importance,  generally  representing 
senile  changes.  Hypertrophy  may  be  inflammatory, 
senile,  or  due  to  new  growths.  Senile  hypertrophy  is 
of  little  moment  in  this  connection,  since,  although  it 
may  interfere  with  the  mechanism  of  ejaculation,  yet  it 
occurs  at  that  period  of  life  when  sexual  activity,  if  not 
on  the  wane,  is  of  slight  importance.  New  growths 
are  rare,  and  when  they  do  occur  the  prominent  symp- 
toms do  not  relate  to  sexnal  disturbances.  Inflam- 
matory conditions  of  the  prostate,  however,  are  of 
importance,  since,  if  they  are  not  secondary  to  inflam- 
mation of  the  vesicles,  they  may  involve  those  sacs  by 
extension.  As  the  feel  of  the  inflamed  prostate  is  or 
ought  to  be  familiar  to  the  surgeon,  a  minute  considera- 
tion of  the  different  phases  presented  will  not  be  at- 
tempted here.      After   the   finger   has    recognized   the 


120  MALE  SEXUAL  ORGANS. 

condition  of  the  prostate  its  posterior  border  should  be 
felt  for.  In  normal  conditions  this  is  easily  distin- 
guishable, especially  in  the  middle,  in  the  position  of 
the  median  notch  between  the  two  so-called  lateral 
lobes,  though  at  either  side  it  is  not  so  well  defined ;  and 
this  is  to  be  expected,  since,  in  studying  the  anatomy  of 
the  part,  it  has  been  seen  that  the  muscular  prostatic 
fibres  on  each  side  extend  back  and  blend  with  the  body 
of  the  vesicle.  This  normal  posterior  prostatic  border 
should  feel  firm,  rounded,  and  unyielding.  Beyond  it 
in  the  median  line,  unless  the  bladder  be  very  full,  the 
tissue  should  be  soft  and  yielding.  On  either  side, 
however,  the  tissues  should  have  more  consistency  and 
more  firmness ;  and  should  the  finger,  making  gentle 
pressure  with  its  tip,  be  moved  from  side  to  side,  the 
vesicles  can  be  made  out.  If,  then,  the  tip  of  the 
finger,  having  located  the  vesical  neck,  be  moved  gently 
backward  and  somewhat  laterally  in  the  anatomical 
direction  of  that  organ  much  of  the  body  of  the  sac 
can  be  felt  as  an  indistinct  pear-shaped  mass.  When 
everything  is  normal  the  vesicles  always  appear  to  be 
composed  of  soft,  elastic  tissue.  Sometimes,  when  the 
perineal  and  levator  ani  muscles  are  tense  and  the  in- 
dividual thick-set,  it  may  be  difficult  to  get  all  this 
information  by  rectal  manipulations,  but  with  practice 
such  instances  will  be  found  to  be  very  few.  In  patho- 
logical conditions  where  the  inflammatory  process  is 
confined  largely  or  wholly  to  one  or  both  of  the  seminal 
vesicles  the  diagnosis  of  a  vesiculitis  is  usually  easy, 
for  then  the  tissues  composing  the  affected  sacs  are  no 
longer  soft  and  elastic,  but  become  more  or  less  rigid 
and  defined,  sometimes  to  such  an  extent  that  the  entire 
lower  two-thirds  of  the  vesicle,  the  portion  in  reach,  can 
be  perfectly  demonstrated.    In  such  instances,  however, 


CLINICAL  FEATURES.  121 

the  vesicle  does  not  usually  appear  normal  in  size,  but 
is  apt  to  be  inflated  by  overdistention.  This  is  owing 
to  the  fact  that,  being  inflamed,  it  has  to  a  degree  lost 
its  expulsive  power.  If  now  pressure  at  all  firm  be 
made  on  this  mass  by  the  tip  of  the  finger,  it  will,  when 
such  is  the  case,  be  found  to  be  indistinctly  fluctuating 
and  somewhat  doughy.  Also,  after  the  pressure  has 
been  removed,  the  mass  will  not  recover  fully  its  former 
shape,  but  it  will  remain  partially  collapsed,  as  it  were ; 
and  associated  with  this  partial  collapse  the  patient  will 
complain  that  something  is  dripping  from  the  end  of 
the  penis.  If  this  complaint  be  investigated,  it  will  be 
found  that  pathological  vesicular  fluid,  such  as  has 
already  been  described,  to  the  extent  oftentimes  of  half 
a  drachm,  and  occasionally  more,  up  to  two  or  three 
drachms,  has  flowed  from  the  meatus  as  the  result  of 
the  pressure  exerted  on  the  vesicle.  Although,  as  has 
been  said,  dilatation  of  the  vesicular  cavity  is  liable  to 
be  a  feature  of  this  grade  of  inflammation,  still  it  varies 
much  in  degree,  and  sometimes  it  is  so  slight  that  it 
cannot  be  distinctly  demonstrated.  In  these  latter  in- 
stances the  vesicles  feel  firm  and  thin.  When  a  vesicle 
feels  large,  however,  it  does  not  follow  that  it  is  greatly 
distended,  for  such  a  feel  may  be,  and  often  is,  due  to 
perivesicular  inflammation.  This  being  the  case,  the 
mass  is  much  harder  and  less  compressible  than  is  usual 
where  the  inflammation  is  confined  to  the  sac-walls. 
Its  contour  is  also  nodular  and  somewhat  irregular,  and 
on  making  pressure  with  the  tip  of  the  finger  the  cavity 
of  the  sac  is  generally  found  to  be  somewhat  distended, 
vesicular  fluid  being  pressed  out  along  the  duct.  Pres- 
sure so  exerted,  however,  does  not  make  nearly  so  much 
impression  on  a  vesiculitis  of  this  nature  as  on  the 
variety  just  previously  considered.    When  perivesicular 


122  MALE  SEXUAL  ORGANS. 

inflammation  is  very  extensive  it  may  fill  up  all  the  space 
around  and  between  the  vesicles,  extending  downward  to 
the  prostate,  laterally  to  the  inner  walls  of  the  pelvis, 
and  upward  beyond  the  reach  of  the  finger.  Such  being 
the  case,  the  posterior  border  of  the  prostate  is  oblit- 
erated, it  being  impossible  to  determine  just  where  that 
body  ends  and  the  induration  begins.  Pressure  on  this 
extensive  induration  shows  the  whole  space  back  of  the 
prostate  to  be  firm,  hard,  and  unyielding,  everything 
being  firmly  adherent  to  the  prostate  and  the  pelvic 
walls.  Sometimes  the  location  of  the  vesicles  in  this 
condition  can  be  made  out  after  a  fashion  by  an  extra 
piling  up  of  the  exudation  round  about  them.  When 
partial  resolution  takes  place  in  such  an  extensive  exu- 
dation a  marked  pitting  appears  in  the  space  between 
the  vesicles,  and  the  whole  mass  becomes  somewhat 
movable.  As  this  absorption  progresses  still  further, 
what  at  first  seems  to  be  the  posterior  border  of  the 
prostate  can  frequently  be  made  out.  This  border, 
however,  extends  further  back  than  normal,  and  gen- 
erally has  a  sharp,  crusty  edge  rather  than  a  smooth 
one.  Such  a  posterior  border  is  in  reality  not  prostate 
at  all,  but  a  fringe  of  exudation  adherent  to  the  pos- 
terior border  of  the  prostate,  the  sharp  edge  representing 
the  portion  where  reabsorption  of  the  exudate  is  chiefly 
taking  place.  Where  an  extensive  exudation  of  this 
nature  is  recent  and  acutely  inflammatory  it  is  not  hard 
and  firm  to  the  feel,  but  cedematous,  such  as  is  usually 
described  by  the  suggestive  term  of  boggy  to  the  feel. 
If  suppurative  changes  ensue  this  bogginess  persists, 
even  though  the  condition  be  most  chronic.  Between 
these  extremes  all  grades  of  perivesiculitis  may  exist, 
but  it  seems  hardly  worth  while  to  attempt  a  description 
of  the  intermediate  varieties.     It  is  well  to  note,  how- 


CLINICAL  FEATURES.  123 

ever,  that  sometimes,  and,  in  fact,  quite  frequently,  these 
processes  are  largely,  if  not  wholly,  unilateral,  as  can 
easily  be  detected  by  the  feel. 

Another  point  to  be  considered  in  this  exploration  is 
the  amount  of  local  pain  or  tenderness  which  it  pro- 
vokes. Chronically  inflamed  vesicles,  especially  when 
distended  and  free  from  perivesiculitis,  are  very  tender 
when  first  touched ;  and  if  pressure  at  all  firm  with  the 
tip  of  the  finger  is  exerted  at  the  time  of  the  first  ex- 
amination numerous  sharp,  painful  sensations,  both  local 
and  reflex,  are  excited.  These  pains  are  frequently  so 
severe  that  the  patient  complains  of  feeling  faint,  and 
occasionally  faintness  may  be  so  pronounced,  especially 
if  the  exploration  be  prolonged,  that  momentary  loss  of 
consciousness  may  result.  Where,  however,  the  peri- 
vesiculitis is  extensive  and  chronic  these  sensations  are 
not  liable  to  be  prominent.  In  such  instances,  in  fact, 
pressure  on  the  indurated  area,  away  from  the  vesicles, 
may  not  be  in  the  least  painful,  while  pressure  directly 
over  the  sac  is  only  moderately  so.  Attention  is  called 
to  the  fact  that  emphasis  is  laid  on  the  point  that  it  is 
the  first  exploration  which  is  liable  to  be  so  painful  in 
certain  of  these  chronic  conditions,  later  manipulations, 
as  will  be  seen  in  considering  treatment,  being  less  and 
less  so,  until  finally  they  provoke  no  sensations  of  this 
nature.  In  other  words,  in  those  conditions  the  pain 
and  tenderness  at  first  provoked  are  neuralgic  in  char- 
acter in  contradistinction  to  the  pain  and  tenderness 
experienced  under  like  conditions  in  acute  seminal  vesi- 
culitis, which  are  inflammatory;  and  should  repeated 
manipulations  in  these  latter  conditions  be  attempted, 
the  pain  and  tenderness  provoked  thereby,  instead  of 
growing  less  and  less,  would   be  augmented  by  each 


124  MALE  SEXUAL  ORGANS. 

exploration,  together  with  the  tumefaction  and  other 
evidences  of  an  increasing  inflammation. 

When  seminal  vesiculitis  exists,  due  to  a  want  of 
muscular  tone,  this  condition  is  oftentimes  indicated  to 
the  finger  on  making  a  rectal  exploration  by  reason  of 
the  generally  relaxed  condition  of  the  various  groups  of 
muscles  encountered  in  this  investigation.  Under  such 
conditions  the  rectal  sphincter  muscle  offers  little  resist- 
ance to  the  finger ;  the  contractions  of  the  perineal  group 
and  of  the  levator  ani,  usually  vigorous,  can  hardly  be 
felt ;  and  the  prostatic  body  can  be  moved  about  with 
ease.  Under  these  conditions  pain  and  tenderness,  due 
to  direct  pressure  on  the  vesicles,  are  not  apt  to  be 
present,  at  least  to  a  marked  degree.  When,  on  the 
contrary,  active  inflammation  exists  in  the  vesicles,  all 
these  muscles  can  be  felt  to  be  in  a  state  of  spasm,  the 
rectal  sphincter  offering  much  resistance,  the  levator  ani 
being  prominent  and  the  prostate  immovable. 

Fig.  18.  Here  the  attempt  has  been  made  to  picture 
the  features  presented  to  the  rectal  feel  in  one  of  these 
pathological  conditions,  such  as  have  just  been  described, 
in  order  to  impress  on  the  reader's  mind  as  vividly  as 
possible  the  points  considered  of  importance  in  this 
connection.  The  picture  represents  the  inner  mucous 
surface  of  the  rectum  and  of  the  bowel  for  a  short  dis- 
tance above  the  rectum.  A  represents  the  rectum ;  B 
B,  the  cut  section  of  the  bowel  above  the  rectum.  A 
cut  has  been  made  through  the  bowel-wall,  beginning 
at  the  back  of  the  anus  and  extending  backward  and 
upward  in  the  direction  of  and  beyond  the  coccyx. 
These  lateral  cut  edges  of  the  bowel  have  then  been 
spread  apart  and  fastened  to  a  flat  surface,  thus  exposing 
its  mucous  surface.  C  C  represents  the  deep  mem- 
branous urethra  with  its  bowel  covering,  a  tack  being 


CLINICAL  FEATURES. 


125 


driven  through  the  bowel  and  into  the  back  structure 
on  each  side  of  the  urethra  in  order  to  make  that  part 
visible.     Just  above  these  two  lateral  urethral  tacks  the 


Fig.  18. 


The  Rectal  Aspect  of  a  Case  of  Chronic  Seminal  Vesiculitis. 

bulging  prostatic  body  is  well  exposed.  Higher  up  on 
each  side  of  the  prostatic  body,  and  just  below  the 
pointers  E  E,  are  seen  two  dark  spots  marking  inden- 


126  MALE  SEXUAL  ORGANS. 

tations.  These  spots  represent  the  location  of  two  more 
tacks,  which  have  been  driven  in  to  bring  out  more  dis- 
tinctly the  contour  of  the  prostate.  The  pointers  E  E 
indicate  the  position  of  the  posterior  border  of  the  pros- 
tate. In  this  picture,  however,  there  is  no  posterior 
border  to  be  seen  in  the  position  indicated  by  the 
pointers ;  and,  in  fact,  if  the  finger  were  placed  there 
in  the  original  specimen  no  border  would  be  felt.  This 
is  because  the  picture  represents  a  case  of  chronic  sem- 
inal vesiculitis,  complicated  with  an  extensive  perivesi- 
culitis,  which  has  filled  up  the  whole  space  back  of  the 
prostate  with  firm  inflammatory  exudation  as  high  up 
as  the  cord  X  Y,  which  has  been  stretched  across  the 
specimen.  The  blade  of  a  scalpel  has  been  tucked  under 
the  cord  in  the  middle  of  the  specimen  in  order  to  show 
the  pitting  at  the  upper  border  of  the  exudation  between 
the  vesicles.  In  the  picture,  owing  to  the  extent  of  the 
exudation,  this  pitting  is  not  so  marked  as  occurs  in 
lighter  grades  of  peri  vesiculitis.  To  the  outer  sides  of 
this  pitting,  below  the  cord  X  Y  and  above  the  two 
lateral  depressions  which  mark  the  spots  where  tacks 
were  driven  to  locate  the  upper  lateral  borders  of  the 
prostate,  are  to  be  seen  two  bulging  prominences,  K  K, 
which  represent  the  seminal  vesicles  imbedded  in  a 
thick  layer  of  inflammatory  exudation  which  entirely 
surrounds  them.  Here,  although  the  cavities  of  the 
vesicles  are  distended,  still  the  exudation  is  so  great 
that  the  prominences  are  firm  and  but  slightly  com- 
pressible. In  this  picture,  although  the  finger  can 
reach  the  lower  portion  of  the  pitting  below  the  end  of 
the  handle  of  the  scalpel,  it  cannot  reach  to  the  posterior 
edge  of  the  exudation  or  over  the  back  portion  of  the 
vesicular  prominences. 

Tubercular  Seminal  Vesiculitis.     This   form  of  disease 


CLINICAL  FEATURES.  127 

may  be  acute,  subacute,  or  chronic.  The  acute  variety 
is  very  rare.  The  other  two  forms  are  common.  These 
diseases,  however,  will  here  require  comparatively  brief 
notice,  not  because  they  are  unimportant,  but  because 
in  most  respects  their  clinical  features  are  the  same  as 
those  pertaining  to  the  corresponding  grades  of  non- 
tubercular  inflammations,  such  as  have  just  been  con- 
sidered. Still  there  are  some  points  of  difference,  and  it 
is  these  which  will  be  noted. 

In  acute  tubercular  vesiculitis  the  local  pain  and 
tenderness  are  not  liable  to  be  so  marked  as  in  the  s:on- 
orrhoeal  variety,  and  reflex  symptoms  are  not  so  promi- 
nent. There  is  a  form  of  acute  vesiculitis,  however,  in 
which  both  tuberculosis  and  gonorrhoea  appear  as  causes. 
This  form  apparently  is  much  commoner  than  the  pure 
and  simple  tubercular  variety.  When  this  double  cause 
exists  the  symptoms  are  usually  severe  and  similar  to 
those  attending  the  acute  gonorrhceal  form.  Subacute 
seminal  vesiculitis  is  more  often  due  to  tuberculosis  than 
to  other  causes.  The  symptoms  also  attendant  on  this 
grade  of  vesiculitis,  when  tubercular,  are  not  apt  to  be 
so  marked  as  those  associated  with  the  other  varieties ; 
and  sometimes  this  form  of  disease  may  have  existed 
for  a  considerable  period  without  having  caused  the 
patient  any  inconvenience,  the  symptoms  having  been 
so  slight  as  to  be  disregarded.  A  certain  amount  of 
sexual  disturbance,  however,  is  almost  always  present, 
sufficient  in  amount  to  be  a  cause  for  complaint,  should 
the  individual  be  inclined  to  exercise  that  function ;  and 
should  the  urine  be  examined,  shreds  from  the  ejacu- 
latory  ducts  or  deep  urethra  will  almost  invariably  be 
found,  together  oftentimes  with  some  free  pus-corpus- 
cles. A  slight  urethral  discharge  is  also  frequently 
present,  sufficient  to  glue  together  the  lips  of  the  meatus. 


128  MALE  SEXUAL  ORGANS. 

If  in  a  case  such  as  this  a  sound  be  passed,  a  deep 
urethral  injection  given,  or,  worst  of  all,  a  gonorrhoea 
contracted,  then  any  of  the  numerous  symptoms  of 
vesiculitis  may  come  suddenly  into  prominence,  the 
slumbering  disease  being  rekindled,  as  it  were,  by  one 
of  these  offending  factors. 

Associated  with  chronic  tubercular  disease  of  the 
parts  there  are  always  marked  symptoms.  It  will  be 
observed,  however,  that  in  the  intervals  of  improved 
general  health  these  symptoms  often  also  improve 
greatly,  much  more  so,  in  fact,  than  occurs  under  like 
conditions  in  the  case  of  other  forms  of  chronic  vesi- 
culitis. With  this  disease,  as  with  the  subacute  variety, 
inflammatory  urethral  and  bladder  affections  often  coexist 
as  symptoms  or  complications. 

In  investigating  all  forms  of  tubercular  seminal  vesi- 
culitis, a  careful  inquiry  into  the  patient's  own  and  family 
history,  together  with  a  thorough  inspection  and  general 
physical  examination,  is  most  important,  as  by  so  doing 
tubercular  evidences  or  tendencies  sufficient  to  impress 
the  surgeon's  mind  are  usually  apparent.  Among  these 
evidences  the  characteristic  tubercular  epididymitis  is 
present  often  enough  to  deserve  special  mention.  In 
the  histories  oftentimes  causes,  such  as  have  already 
been  studied,  appear,  partially  at  least,  to  account  for 
tubercular  disease  in  the  vesicles  ;  but  in  some  instances 
there  is  no  special  apparent  cause,  aside  from  the  gen- 
eral tubercular  diathesis,  to  attract  the  inflammatory 
process  to  these  parts.  In  such  instances  the  disease 
usually  begins  insidiously  as  a  subacute  vesiculitis,  with 
few  attendant  symptoms,  finally  becoming  chronic,  and 
manifesting  itself  by  numerous  and  severe  accompani- 
ments. It  has  long  been  recognized  that  gonorrhoea  in 
a  tubercular  subject  is  a  disease  to  be  dreaded ;  in  fact, 


CLINICAL  FEATURES.  129 

it  is  common  for  such  individuals  to  ascribe,  and  rightly, 
too,  the  commencement  of  a  permanent  deterioration  in 
health  to  this  agent,  which  may  have  furnished  the 
tubercle  bacilli  just  the  conditions  requisite  for  their 
propagation  and  proliferation.  In  such  instances  the 
seminal  vesicles  are  the  parts  which  generally  afford 
these  germs  their  first  permanent  foothold. 

As  regards  physical  signs  resulting  from  rectal  ex- 
ploration, there  is  nothing  by  which  acute  tubercular 
vesiculitis  can  be  distinguished  from  the  gonorrhoeal 
variety.  In  the  case  of  subacute  tubercular  disease, 
however,  the  finger  usually  detects  more  thickening  of 
the  sac  walls  and  more  distention,  together  with  less 
tenderness  than  is  usual  in  the  case  of  the  non-tuber- 
cular forms.  Sometimes  also  with  this  grade  of  disease 
a  moderate  amount  of  perivesiculitis  may  be  present — a 
feature  which  is  never  associated  with  simple  subacute 
vesiculitis.  Chronic  tubercular  vesiculitis  is  almost 
always  associated  with  a  marked  degree  of  perivesicular 
induration ;  but,  as  such  an  induration  is  a  frequent 
accompaniment  of  other  varieties  of  chronic  vesiculitis, 
it  is  not  necessarily  a  distinguishing  feature.  In  the 
chronic,  as  in  the  subacute,  tubercular  cases  compara- 
tively little  pain  or  tenderness  is  usually  experienced 
from  the  exploratory  rectal  manipulation.  If,  however, 
several  such  manipulations  be  undertaken  at  short  in- 
tervals in  this  class  of  cases,  considerable  pain  and  ten- 
derness may  eventually  be  provoked,  occasioned  by  a 
stirring  up  of  the  tubercular  processes ;  whereas  with 
other  varieties  of  these  same  grades  of  inflammation  the 
first  rectal  manipulation  usually  provokes  the  greatest 
pain  and  tenderness,  subsequent  ones  being  attended  by 
less.  Considerable  stress  will  be  laid  on  this  point  in 
the  chapter  on  treatment. 

9 


130  MALE  SEXUAL  ORGANS. 

In  cases  where  the  physical  signs  point  toward  tuber- 
cular involvement  of  the  vesicle,  it  is  always  well  to 
examine  the  inflammatory  material  expressed  from  the 
sac  for  the  tubercle  bacillus  in  order  to  confirm  the 
diagnosis. 

It  has  not  seemed  worth  while  to  endeavor  to  enu- 
merate the  clinical  features  attendant  on  malignant 
disease  of  the  vesicles,  or  on  the  other  rare  pathological 
processes  which  may  affect  these  parts,  since,  owing  to 
the  meagre  clinical  records  attached  to  the  few  cases 
of  this  description  which  have  been  reported,  anything 
approaching  completeness  in  such  an  attempt  would  be 
impossible. 


CHAPTEE    V. 

DIFFERENTIAL    DIAGNOSIS. 

If  one  will  familiarize  himself  with  the  clinical  feat- 
ures of  seminal  vesiculitis  in  its  various  forms  and 
intensities,  there  need  be  little  danger  of  mistaking  the 
disease.  Still,  as  it  has  been  customary  until  very 
recently  either  to  ignore  the  existence  of  these  organs, 
or,  at  most,  to  give  them  but  a  passing  thought  in 
making  a  diagnosis,  very  many  errors  have  resulted. 
While  some  of  these  errors  have  been  unpardonable, 
others  have  been  natural,  since  the  standard  authorities 
have  ascribed  to  various  other  conditions  many  of  the 
symptoms  really  dependent  on  seminal  vesiculitis.  It 
has,  therefore,  seemed  well  to  devote  some  space  to  a 
consideration  of  the  diseases  such  as  might  be,  and 
probably  often  have  been,  mistaken  for  these  inflamma- 
tions. In  so  doing,  the  diseases  which  may  simulate 
acute  seminal  vesiculitis  will  receive  first  attention. 
These  are  the  acute  varieties  of  prostatitis,  cystitis,  and 
posterior  urethritis ;  also  stricture,  peritonitis,  acute 
appendicitis,  acute  epididymitis,  acute  pyelitis,  kidney 
colic,  and  acute  inflammations  pertaining  to  the  rectum. 

Acute  prostatitis  is  probably  mistaken  for  acute  sem- 
inal vesiculitis  oftener  than  any  other  disease.  Occa- 
sionally these  two  diseases  coexist.  An  acute  suppura- 
tive prostatitis  ending  in  abscess-formation,  the  pus 
finally  discharging  itself  into  the  bladder,  is  often 
mentioned  in  literature.  The  firm  muscular  structure 
of  the  prostate,  however,  together  with  an  absence  of 


132  MALE  SEXUAL   ORGANS. 

pathological  specimens  illustrating  instances  where  such 
a  condition  of  affairs  has  taken  place,  has  made  the 
author  skeptical,  if  not  concerning  the  existence  of  such 
cases,  at  least  of  their  frequency.  Most  instances  of 
this  nature  probably  represent  abscess-formation  in  con- 
nection with  peri  vesiculitis.  In  cases  where  there  are 
much  vesical  tenesmus  and  frequency  of  urination,  at- 
tended with  pain  and  supra-pubic  tenderness,  together 
with  free  pus  in  the  urine  or  thick,  deep  urethral  shreds, 
acute  cystitis  or  posterior  urethritis  may  be  simulated ; 
or  if  associated  with  frequent  urination  and  tenesmus 
extensive  deep  urethral  spasm,  complicated  in  some 
cases  with  more  or  less  tumefaction  of  this  region, 
exists,  the  result  being  a  fine,  dribbling  stream,  or  in 
extreme  instances  absolute  retention,  then  urethral  strict- 
ure is  simulated.  In  all  these  cases  examination  per 
rectum  will  demonstrate  acute  seminal  vesiculitis,  which 
is  sufficient  in  itself  to  account  for  all  the  symptoms. 
In  cases,  however,  where  organic  stricture  is  simulated, 
besides  demonstrating  the  existence  of  the  vesiculitis, 
it  may  be  necessary  to  demonstrate  the  spasmodic  nature 
of  the  urethral  obstruction,  which  can  easily  be  done  by 
passing  a  blunt  steel  sound  just  through  the  membranous 
urethra.  Deeper  than  that  it  is  not  necessary  or  advis- 
able to  go,  for  fear  of  intensifying  the  vesicular  inflam- 
mation. When  pelvic  peritonitis  is  present  as  a  com- 
plication the  source  of  the  trouble  may  be  overlooked, 
the  peritoneum  being  considered  the  seat  of  the  disease ; 
or  when  peritonitis  exists,  together  with  an  exudative 
perivesiculitis  so  extensive  that  it  can  be  detected  by 
abdominal  palpation,  then  acute  appendicitis  may  be 
suspected.  Sometimes  an  acute  epididymitis  may  co- 
exist, in  which  case  the  whole  attention  may  be  directed 
to  that  part,  the  vesiculitis  being  overlooked.     Again, 


DIFFERENTIAL  DIAGNOSIS.  133 

where  the  pain  is  radiated  upward  toward  the  kidney, 
there  being  much  pus  in  the  urine,  acute  pyelitis  may  be 
diagnosed ;  or  if  such  pain  exists,  there  being  at  the 
time  of  examination  little  or  no  pus  in  the  urine,  then 
the  trouble  may  be  attributed  to  some  form  of  renal 
colic.  Where  pain  is  referred  to  the  rectum,  a  super- 
ficial observer  might  diagnose  the  case  as  one  of  local- 
ized or  general  rectal  inflammation. 

The  diseases  which  may  be,  and  often  are,  confounded 
with  the  different  forms  of  subacute  and  chronic  seminal 
vesiculitis  are  as  numerous  and  varied  as  the  symptoms, 
both  direct  and  indirect,  which  are  attendant  on  these 
conditions,  the  error  in  diagnosis  usually  being  to  con- 
sider a  prominent  symptom  the  disease  itself  rather  than 
simply  a  symptom  of  disease.  As  the  diseases  which 
might  be  so  mistaken  for  these  forms  of  vesiculitis  are 
many,  a  mention  in  detail  of  them  will  not  be  attempted, 
but  the  subject  will  be  considered  in  a  somewhat  general 
manner,  emphasis  being  laid  on  the  points  which  have 
seemed  to  the  author  in  his  clinical  studies  to  be  of  prime 
importance.  It  is  well  to  divide  this  subject  into  two 
parts — first,  and  less  frequent,  instances  where  from  the 
symptoms  present  seminal  vesiculitis  is  wrongly  sup- 
posed to  exist  as  a  cause ;  second,  instances  where  symp- 
toms due  to  a  seminal  vesiculitis  are  mistaken  for  various 
other  diseases. 

Under  the  first  heading,  attention  is  called  to  a  class 
of  individuals  very  poorly  developed  physically,  suffer- 
ing really  from  general  debility,  who  have  focused  their 
attention  on  their  sexual  organs  to  such  an  extent  that 
supposed  disease  in  that  part  is  held  to  be  the  source  of 
their  ill  health.  Their  complaint  is  sexual  weakness. 
If  they  attempt  sexual  intercourse,  the  erection  is  weak, 
the  emission  premature,  and  there  is  a  feeling  of  exhaus- 


134  MALE  SEXUAL  ORGANS. 

tion  or  prostration  after  the  attempt.  They  are  often 
troubled  by  frequent  nocturnal  emissions,  and  sometimes 
emissions  occur  at  the  mere  sight  of  an  attractive  woman. 
A  general  examination,  however,  will  show  that  the 
sexual  organs  are  no  weaker  than  their  other  organs. 
Their  lung-expansion  will  be  found  to  be  defective,  and 
their  circulation  poor.  In  several  instances  seen  by  the 
author  defects  in  the  heart  were  discovered,  some  of 
which  appeared  to  be  congenital.  Any  physical  or 
mental  attempt  will  generally  cause  exhaustion.  An 
examination  of  the  vesicles  will  show  no  localized  in- 
flammation, and  treatment  directed  toward  these  organs 
will  do  no  good.  If,  however,  the  general  physical  con- 
dition can  be  improved  by  agents,  directed,  for  instance, 
toward  the  heart,  lungs,  or  alimentary  canal,  it  will  be 
found  that  a  corresponding  improvement  in  the  sexual 
symptoms  will  take  place. 

There  is  another  class  of  individuals,  often  physically 
robust,  and  sometimes  athletic  to  such  a  degree  as  to  be 
famous,  who  present  themselves  to  the  surgeon  com- 
plaining of  sexual  weakness.  Their  special  complaint 
usually  is  that  erection  fails  them  on  attempting  coitus, 
there  being  no  ejaculation,  or  that  the  ejaculation,  asso- 
ciated with  a  failure  of  erection,  occurs  as  soon  as  the 
act  is  attempted  and  before  an  entrance  is  effected. 
Their  sexual  sensations  are  usually  all  right,  and  they 
generally  state  that  they  often  awaken  in  the  morning 
with  a  strong  and  natural  erection ;  and,  in  fact,  that 
their  erections  resulting  from  sexual  thoughts  and  sur- 
roundings are  natural  and  strong.  An  examination  of 
the  seminal  vesicles  will  show  the  organs  to  be  normal. 
These  are  instances  of  functional  impotence,  the  sexual 
failure  being  due  to  shyness,  fear  of  contagion,  dislike, 
etc.     Functional  impotence  is  met  most  frequently  in 


DIFFERENTIAL  DIAGNOSIS.  135 

young  unmarried  men  little  used  to  female  society. 
"With  them  the  first  attempt  at  coitus  having  resulted 
in  a  failure,  more  or  less  complete,  from  one  of  the  above 
enumerated  causes,  subsequent  attempts  are  liable  to  be 
worse,  there  being  less  confidence.  Sometimes  they  can 
perform  the  act  perfectly  satisfactorily  with  some  one 
woman  of  whom  they  are  fond  or  who  has  their  confi- 
dence, failure  following  like  attempts  undertaken  with 
others.  In  such  instances  fear  of  contagion  or  fastidi- 
ousness rather  than  shyness  may  be  the  cause.  Some- 
times a  married  man,  at  first  apparently  all  right  sexu- 
ally, may  gradually  or  suddenly  find  himself  functionally 
impotent  or  sexually  weak  with  his  wife.  This  is 
usually  the  result  of  some  incompatibility,  the  fault 
lying  with  the  wife.  The  author  has  in  mind  an  extreme 
case  illustrating  this  condition.  A  very  nervous  man  of 
thirty-six  years  sought  advice  for  sexual  weakness  such 
as  has  been  described.  He  had  been  married  about  five 
years,  and  for  a  time  had  experienced  no  difficulty  in 
performing  the  sexual  act,  and  had,  in  fact,  impregnated 
his  wife.  His  wife,  however,  apparently  had  no  feminine 
instincts.  She  experienced  no  pleasure  from  the  sexual 
act;  in  fact,  she  thought  it  vulgar  and  unbecoming, 
submitting  to  it  only  as  being  a  part  of  the  marital 
contract.  "When  her  husband  was  in  the  midst  of  his 
sexual  attempts  she  frequently  essayed  to  divert  her 
mind  by  reading,  asking  him  from  time  to  time  if  he 
were  through.  The  result  was  at  first  a  marked  damp- 
ening in  the  sexual  enthusiasm  of  the  husband,  followed 
later  by  a  weakness  so  marked  as  to  be  little  short  of 
impotency.  This  state  of  affairs  may  be  seen  in  widowers 
who  have  lost  dearly  beloved  wives.  All  these  indi- 
viduals, if  happily  married,  cease  to  complain  of  their 
sexual  apparatus,  that  function  becoming  normal  again 


136  MALE  SEXUAL  ORGANS. 

in  every  respect.  Another  class  coming  under  this  first 
heading  are  those  which  really  belong  to  the  alienist. 
In  the  introductory  chapter  the  point  has  been  empha- 
sized that  hitherto,  judging  from  the  writings  on  the 
subject,  this  class  has  been  supposed  by  the  medical 
profession  at  large  to  be  very  extensive  and  numerous. 
Such,  however,  the  author  holds  is  not  the  case,  these 
ideas  being  prevalent  only  because  no  one  has  heretofore 
demonstrated  the  importance  of  seminal  vesiculitis  or 
classified  the  symptoms  dependent  on  it.  Many  idiots 
and  others  mentally  deficient  will  not  attempt  sexual 
intercourse,  though  persistent  masturbators.  Such 
creatures,  although  incapable  of  describing  their  feel- 
ings, have  often  erroneously  been  confounded  with  cases 
of  sexual  weakness.  It  is  needless  to  state  that  no 
vesicular  disease  is  present  in  these  idiot  cases  ;  in  fact, 
it  would  be  interesting  to  investigate  whether  their 
sexual  apparatus  be  fully  developed.  Some  forms  of 
paranoia,  mania,  melancholia,  and  structural  disease  of 
the  brain  may  have  some  such  symptoms  associated 
with  them  as  to  make  it  worth  while  to  examine  the 
seminal  vesicles  in  order  to  exclude  disease  localized  in 
that  quarter. 

Rarely  hysteria  in  the  male  may  give  rise  to  symp- 
toms exactly  similiar  to  those  associated  with  seminal 
vesiculitis.  Such  cases  are  often  very  misleading,  and 
unless  the  surgeon  exercises  care  and  is  skilled  in  the 
rectal  feel  he  generally  diagnoses  them  as  seminal  vesi- 
culitis. The  reason  for  this  is  that  these  hysterical 
individuals  always  hold  themselves  most  rigid  when  an 
attempt  at  rectal  digital  exploration  is  made,  and  cry 
out  apparently  with  great  pain  as  the  finger  attempts  to 
examine  the  condition  of  the  vesicles.  If,  however,  the 
examination  is  persisted  in  and  completed,  the  vesicles 


DIFFERENTIAL  DIAGNOSIS.  137 

will  be  found  to  be  all  right.  It  will  also  be  found  that 
the  individual  complains  of  just  as  much  pain  no  matter 
against  what  or  in  what  direction  the  tip  of  the  finger 
is  pressed.  If  a  mistake  be  made,  and  one  of  these 
cases  be  diagnosed  as  seminal  vesiculitis  and  the  regular 
treatment  advocated  for  that  disease  be  attempted,  no 
good  results  are  apt  to  follow ;  but  new  and  wonderful 
groups  of  strange  and  apparently  distressing  symptoms 
are  liable  to  be  complained  of  as  the  results  of  the 
treatment. 

We  now  come  to  the  consideration  of  the  second 
part,  which  includes  instances  where  symptoms  of  sem- 
inal vesiculitis  have  been  mistaken  for  various  other 
diseases.  Symptoms  relating  to  the  urethra  and  bladder 
will  receive  first  attention,  as  being  the  chief  causes  for 
error.  Persistent  urethral  discharges,  when  simply 
symptomatic  of  a  vesiculitis,  have  been  so  frequently 
mistaken  for  localized  urethral  disease  that  the  author 
has  deemed  it  wise  to  write  a  thesis  on  this  subject 
{Journal  of  Cutaneous  and  Genito- Urinary  Diseases, 
June  and  July,  1894),  in  which  many  cases  are  cited 
which  had  hitherto  subjected  themselves  to  all  known 
forms  of  urethral  treatment,  in  a  number  of  instances 
at  the  hands  of  surgeons  most  distinguished  in  genito- 
urinary diseases,  without  having  experienced  any  relief. 
Very  many  cases  of  vesiculitis  have  been  diagnosed 
cystitis  or  posterior  urethritis,  granular  urethritis,  or 
stricture,  and  treated  as  such.  If  the  means  of  treat- 
ment employed  in  these  mistaken  diagnoses  have  been 
mild  and  gentle,  the  results  have  usually  been  of  a 
negative  nature.  If,  on  the  other  hand,  they  have  been 
severe,  such  as  strong  deep  urethral  injections  or  lavage, 
strong  topical  applications  through  the  endoscope,  the 
passage  of  large  and  tight  sounds,  especially  through 


138  MALE  SEXUAL  ORGANS. 

the  entire  length  of  the  deep  urethra,  then  the  results 
have  probably  been  disastrous.  On  the  theory,  which 
has  been  quite  prevalent,  that  all  persistent  discharges 
are  due  to  urethral  stricture,  internal  urethrotomy  fre- 
quently and  external  urethrotomy  occasionally  have 
been  resorted  to  in  the  hope  of  accomplishing  a  cure. 
It  is  needless  to  state  that  the  results  from  these  opera- 
tions undertaken  in  such  conditions  are  disappointing 
to  both  surgeon  and  patient.  The  author  was  once 
consulted  by  an  individual  with  seminal  vesiculitis  in 
whose  mind  the  idea  that  urethral  stricture  was  the 
cause  of  his  trouble  had  become  so  firmly  fixed  that 
internal  urethrotomy  had  been  resorted  to  seventeen 
times.  The  fact  that  a  cure  had  not  resulted  from  these 
numerous  attempts  was  ascribed  to  the  fact  that  none 
of  them  had  been  really  thorough,  there  being  ine- 
qualities in  the  canal  always  to  be  found  after  every 
operation.  The  mistake  of  diagnosing  chronic  seminal 
vesiculitis  as  chronic  pyelitis  is  not  uncommon,  and 
sometimes  considerable  study  and  attention  are  required 
in  making  the  correct  differential  diagnosis.  It  is  in 
the  cases  of  chronic  seminal  vesiculitis,  complicated  by 
bacterial  infection,  that  the  resemblance  to  pyelitis  is 
usually  most  marked.  Here  there  may  be  no  symptoms 
pointing  toward  bladder-irritation,  but  still  in  the  urine 
some  pus  and  numerous  bacteria,  causing  a  glazy,  murky 
appearance,  together  with  a  trace  of  albumin.  Exam- 
inations of  the  bladder  by  searchers,  cystoscopes,  etc., 
usually  fail  to  show  anything  pathological  in  connection 
with  that  organ,  although  such  manipulations  are  fre- 
quently followed  by  reactionary  chills.  The  vesicles 
being  overlooked,  the  diagnosis  of  pyelitis  naturally 
follows,  the  chill  being  looked  upon  as  especially  indi- 
cative of  renal  reaction.     If,  however,  in  one  of  these 


DIFFERENTIAL  DIAGNOSIS.  139 

deceptive  cases  the  vesicles  be  examined,  they  will  be 
found  to  be  diseased ;  and  should  the  urine  be  voided 
after  these  sacs  have  been  largely  emptied  of  their  con- 
tents, by  means  of  rectal  digital  manipulation,  the  fluid 
will  be  found  to  be  charged  with  bacteria  and  pus  in 
greater  abundance  than  usual;  and  should  the  micro- 
scope be  employed,  the  vesicular  origin  of  much  of  the 
sediment  will  be  demonstrated.  The  urine  also  voided 
subsequent  to  such  a  manipulation  will  frequently  be 
exceptionally  clear.  On  the  other  hand,  contrary  to 
what  would  be  expected  with  a  pyelitis,  flushing  the 
kidneys  in  these  cases,  together  with  the  administration 
of  drugs  tending  to  sterilize  the  urine,  are  measures 
attended  by  negative  results. 

Sometimes  where  the  symptoms  simulate  those  atten- 
dant on  vesical  inflammations,  vesical  calculus,  tumor, 
or  tubercle  may  be  thought  to  be  present. 

Chronic  prostatitis  is  the  disease  alleged  in  very  many 
instances  to  be  the  cause  of  symptoms  really  dependent 
on  a  chronic  seminal  vesiculitis.  The  true  clinical  feat- 
ures, however,  of  chronic  prostatitis  are  mostly  nega- 
tive, except  in  those  instances  where  hypertrophy  of 
the  gland  results,  occasioning  thereby  symptoms  due 
to  defective  urinary  drainage.  Posterior  urethritis  is  a 
disease  often  supposed  to  be  chronic  prostatitis  ;  in  fact, 
some  years  ago,  before  deep  urethral  diseases  had  been 
thoroughly  studied,  it  was  customary  to  ascribe  to  a 
prostatitis  most  deep  urethral  symptoms.  Consequently 
the  term  chronic  prostatitis  was  in  more  frequent  use 
then  than  at  present. 

When  pains  or  unusual  sensations  due  to  a  vesicu- 
litis are  referred  to  the  scrotum  or  testicles,  these  parts 
are  usually  examined  carefully  by  the  patient  or  his 
attending  physician ;  and  should  a  varicocele,  as  is  fre- 


140  MALE  SEXUAL  ORGANS. 

quent,  a  hydrocele,  a  cyst,  or,  indeed,  anything  patho- 
logical or  strange  be  discovered,  then  the  cause  of  the 
symptoms  is  supposed  to  have  been  found.  The  author 
has  on  numerous  occasions  been  consulted  by  indi- 
viduals of  this  description.  They  generally  announce 
that  they  have  something,  frequently  a  varicocele,  which 
is  giving  them  much  trouble.  They  are  so  sure  that 
the  varicocele,  for  instance,  is  the  cause  for  their  suf- 
fering that  they  rarely  ask  the  consultant's  opinion  on 
that  point,  but  simply  want  to  know  if  he  will  remove 
the  offending  cause,  together  with  the  details  of  opera- 
tion, cost,  etc.  It  is  always  well  for  the  surgeon  to  be 
on  his  guard  with  these  cases,  for  if  he  operates  as  the 
patient  desires  the  result  is  disappointing  to  all  con- 
cerned. The  way  to  manage  them  is  to  advocate,  first 
of  all,  a  cure  of  the  vesiculitis.  Then,  if  the  scrotal 
condition  still  gives  trouble,  it  can  be  remedied  later. 

Another  frequent  source  of  error  is  to  suppose  that 
some  pathological  condition  of  the  rectum  exists  to 
account  for  the  vesicular  symptoms.  "With  this  object 
in  view,  a  careful  examination  of  that  organ  is  often 
made,  and,  especially  if  the  surgeon  be  enthusiastic, 
something  is  usually  found,  be  it  an  abrasion,  fissure, 
hemorrhoid,  ulcer,  spasmodic  sphincter,  mucous  tab,  or 
even  a  mucous  pouch  above  the  sphincter.  This  some- 
thing is  then  treated  and  removed.  A  number  of  cases 
of  chronic  vesiculitis  have  come  to  notice  where  rectal 
operations,  often  of  a  severe  nature,  have  been  undergone 
in  a  futile  search  for  relief.  One  of  these  cases,  besides 
having  had  his  urethra  cut  and  a  varicocele  removed, 
had  had  his  sphincter  stretched  on  numerous  occasions, 
rectal  tabs  removed,  and  so-called  mucous  pouches  cut 
out.  Another  operative  fad  much  in  this  line,  an  ex- 
ample of  which  has  been  observed,  was  the  removal  of 


DIFFERENTIAL  DIAGNOSIS.  141 

the  coccyx  for  reflex  vesicular  pain  located  in  that  part. 
Some  cases  of  light-grade  seminal  vesiculitis  do  get  a 
certain  amount  of  benefit  from  general  rectal  treatment. 
This  is  probably  owing  to  the  accidental  pressure  ex- 
erted on  the  distended  sacs  by  bougies,  specula,  instru- 
mentation, manipulation,  etc.  For  this  reason  the 
stretching  of  the  rectum  by  certain  specified  specula, 
the  introduction  of  rectal  bougies  and  the  like,  have 
been  advocated  from  time  to  time,  generally  by  irreg- 
ular practitioners,  as  a  cure  for  sexual  weakness  and 
kindred  complaints  in  the  male. 

Indirect  reflex  symptoms  may  be  misleading  and 
puzzling ;  in  fact,  allusion  has  already  been  made  to  a 
case  which  the  author  mistook  for  intestinal  colic.  As, 
however,  these  symptoms  are  so  varied  it  has  not  seemed 
worth  while  to  try  to  consider  them  from  the  differential 
diagnostic  point  of  view,  an  enumeration  of  them  in  the 
chapter  on  clinical  features  being  all  that  has  been 
deemed  necessary. 

From  the  mental  symptoms  presented  in  many  cases 
of  subacute  or  chronic  seminal  vesiculitis,  it  has  been 
usual,  as  has  been  stated,  to  locate  the  cause  of  trouble 
in  the  head.  Although  this  error  has  been  frequent,  and 
the  avoidance  of  it  is  most  important  as  regards  prog- 
nosis, still  the  discussion  of  the  subject  requires  but 
little  space  in  this  connection.  The  great  point  with 
these  cases  is  to  bear  the  seminal  vesicles  in  mind,  to 
question  the  patient  regarding  localized  symptoms  of 
vesiculitis,  and,  lastly,  to  examine  the  vesicles  them- 
selves by  means  of  the  digital  rectal  feel.  If  seminal 
vesiculitis  is  found  to  exist,  then  the  chances  are  that 
the  mental  symptoms  depend  upon  it,  as  can  be  defi- 
nitely demonstrated  by  their  disappearance  as  a  cure  of 
the  vesiculitis  is  effected. 


CHAPTEE    VI. 

TREATMENT    AND    PROGNOSIS. 

The  treatment  to  be  pursued  in  a  given  case  of  sem- 
inal vesiculitis  depends  much  upon  its  quality — that  is 
to  say,  measures  which  would  be  efficacious  in  the  sub- 
acute or  chronic  varieties  might  be,  and  probably  would 
be,  extremely  harmful  if  undertaken  in  acute  or  tuber- 
cular conditions.  It  is  well,  therefore,  in  treating  this 
subject  to  subdivide  it  according  to  the  grades  of  dis- 
ease requiring  differences  in  treatment.  In  detailing  the 
treatment  appropriate  to  these  different  grades,  the  re- 
sults to  be  expected,  or,  in  other  words,  the  prognosis, 
will  also  be  considered.  The  subdivisions  to  be  made 
are  as  follows  :  1.  Treatment  of  acute.  2.  Treatment 
of  subacute  and  chronic.  3.  Treatment  of  the  tuber- 
cular forms  of  seminal  vesiculitis. 

Treatment  of  Acute  Seminal  Vesiculitis.  The  most 
important — in  fact,  the  chief — feature  in  the  treatment  of 
this  condition  consists  in  absolute  rest  in  bed  until  all 
localized  inflammatory  symptoms  have  disappeared,  and 
until  all  inflammatory  evidences  to  be  discovered  by  the 
rectal  feel  have  been  either  entirely  absorbed  or  so  re- 
duced that  further  rest  is  found  to  be  negative  of  good 
results.  The  patient  should  lie  flat  on  his  back,  with 
his  shoulders  low.  It  is  at  times  even  a  good  plan  to 
raise  the  foot  of  the  bed,  as  is  done  by  gynecologists 
for  some  pelvic  inflammations.  By  so  doing  all  blood- 
tension  possible  is  removed  from  the  region  of  the 
vesicles.     Then  the  testicles,  regardless  of  whether  they 


TEE  A  TMENT  AND  PR  0  GNOSIS.  1 43 

be  involved  in  the  inflammation  or  not,  should  always 
be  drawn  np  and  supported  on  the  pubic-bone,  thus 
removing  all  drag  and  pull  from  the  vasa  deferentia. 
The  author,  in  an  article  on  the  requisites  of  a  suspen- 
sory-bandage {Journal  of  Cutaneous  and  Oenito-  Uriyiary 
Diseases,  February,  1894),  has  described,  together  with 
a  diagram,  the  appliance  required  in  cases  where  it  is 
necessary  to  maintain  this  position  of  the  testicles.  As 
this  description  is  of  importance  in  this  connection,  it 
has  seemed  well  to  quote  it. 

"In  cases  where  it  is  necessary  for  the  patient  to 
remain  in  bed  with  his  testicles  supported,  as  is  fre- 
quently required  in  active  inflammatory  conditions,  such 
as  acute  epididymitis,  the  forms  of  support  which  we 
have  already  considered,  and  which  apply  to  walking- 
cases,  are  not  suitable,  and  another  device  is  called  for. 
In  these  inflammatory  cases  the  patient  should  lie  flat 
on  his  back.  His  testicles  should  not  be  allowed  to 
hang  at  all,  but  should  be  drawn  up  and  placed  on  the 
pubic-bone,  and  allowed  to  remain  there.  Fig.  19  rep- 
resents the  required  form  of  support  in  such  instances. 
This  support  can  be  adjusted  at  the  bedside,  firm 
muslin  and  safety-pins  alone  being  required.  A  broad 
waistband  is  first  firmly  applied,  and  then  to  this  a  broad 
sling  is  pinned,  which  includes  the  testicles,  holding 
them  in  their  suprapubic  position.  The  penis  naturally 
lies  upward  on  the  hypogastrium,  as  seen  in  the  diagram. 
To  prevent  this  sling  from  slipping  up,  back-straps, 
which  cannot  be  represented  in  the  drawing,  are  ad- 
justed ;  and  to  guard  against  the  testicles  slipping  over 
the  rim  of  the  loop,  in  case  the  patient  is  restless,  a 
strip  of  muslin  is  pinned  across,  as  seen  in  the  figure. 
Oftentimes,  however,  in  these  cases  the  inflamed  parts 
are  so  tender  that  they  cannot  be  brought  directly  in 


144 


MALE  SEXUAL  ORGANS. 


contact  with  any  support,  as  represented  in  the  figure, 
but  require  to  be  done  up  in  poultices,  fomentations, 
cotton,  wool,  etc.,  as  the  case  may  be.  Still,  no  matter 
in  what  substances  they  may  be  enveloped,  the  position 
of  the  testicles,  resting  on  the  pubes,  should  be  main- 
tained ;  and  such  can  readily  be  done  by  the  apparatus 
just  described,  only  in  these  latter  instances  the  loop 
fastened  to  the  waistband  should  be  made  extensive 
enough  to  include  the  scrotal  wrappings.'' 

Fig.  19. 


Reclining. 


With  many  of  these  cases,  during  this  period  of  rest 
in  bed,  comparatively  little  other  treatment  is  necessary 
aside  from  close  attention  to  the  bowels.  These  organs 
should  not,  on  the  one  hand,  be  scoured  by  violent  ca- 
thartics, nor,  on  the  other,  be  allowed  to  become  con- 
stipated, since  both  such  conditions  are  unfavorable  to 
the  vesiculitis.  Mild  laxatives  should  be  daily  admin- 
istered, and  should  these  not  be  in  themselves  sufficient 
their  action  should  be  aided  by  rectal  enemata  of  hot 
water,  or,  in  more  stubborn  cases,  of  hot  water  to  which 


TREA  TMENT  AND  PR  0  GNOSIS.  145 

common  salt  to  the  amount  of  a  tablespoonful  or  two 
to  the  quart  has  been  added.  In  administering  these 
enemata  it  will  be  found  in  most  cases  advisable  to 
employ  a  long,  soft-rubber  rectal-tube,  the  end  of  which 
can  be  gently  pushed  up  beyond  the  sigmoid  flexure 
rather  than  the  ordinary  short,  hard-rubber  nozzle.  Hot 
fomentations  or  poultices,  extensive  enough  to  cover  the 
entire  lateral  hypogastric  region  corresponding  to  the 
vesicle  involved,  are  frequently  very  beneficial  during 
the  early  stage  of  the  disease,  especially  if  there  be 
much  pain  associated  with  abdominal  tenderness.  After, 
however,  the  fever  falls  and  gushes  of  pus  from  the 
affected  vesicle  appear  in  the  urine,  then  it  is  better  to 
discontinue  these  applications.  Instead  of  hot  agents 
cold  ones  may  in  a  few  instances  be  of  value,  an  ice- 
pack being  employed.  A  trial  of  cold  applications, 
however,  is  recommended  only  in  case  hot  ones  have 
failed  to  occasion  relief,  and  even  then  their  employment 
should  be  of  but  a  few  days'  duration.  In  many  in- 
stances during  the  acute  stage  anodynes  sufficient  to 
render  the  patient  comfortable  are  required.  Supposi- 
tories of  morphine  (gr.  J)  and  extract  of  belladonna 
(gr.  J),  every  six  to  eight  hours,  often  accomplish  this 
result  in  a  very  satisfactory  manner ;  but  in  cases  where 
the  pain  is  intense  and  paroxysmal,  such  as  is  liable  to 
exist  where  rest  in  bed  has  not  been  promptly  enforced 
at  the  beginning  of  trouble,  a  full  dose  of  morphine  in 
the  form  of  an  hypodermic  injection  may  be  desirable. 
In  many  instances  after  the  pain  has  once  been  subdued 
by  morphine  a  lighter  anodyne,  such  as  codeine,  in  occa- 
sional doses  of  from  one-sixth  to  one-fourth  of  a  grain, 
will  be  found  sufficient  to  insure  comfort.  The  admin- 
istration of  anodynes  in  the  engorgement  stage  of  an 

acute  vesiculitis  is  recommended  not  onlv  in  order  to 

10 


146  MALE  SEXUAL  ORGANS. 

render  the  patient  comfortable,  but  also,  and  especially, 
in  order  to  rid  the  inflamed  part  of  muscular  spasm  and 
tension,  both  of  which  serve  to  aggravate  the  inflam- 
mation. As  soon  as  the  fever  breaks  and  the  vesicle 
begins  to  discharge  itself,  then  the  administration  of 
anodynes  should  be  discontinued.  Phytolacca  decandra 
is  a  drug  which  is  often  of  value  in  the  engorgement 
stage  of  this  disease,  by  exerting  a  favorable  effect  on 
the  pain  and  inflammation.  It  may  be  given  in  10-minim 
doses  of  the  tincture  every  four  to  six  hours.  Iodide 
of  potash  also,  in  this  as  in  other  inflammations,  may 
modify  the  inflammatory  process.  This  drug  in  5  to 
10-grain  doses  may  with  benefit  be  combined  with 
Phytolacca  decandra.  If  the  patient  has  a  strumous 
tendency,  convalescence  may  be  hastened  by  the  ad- 
ministration of  cod-liver  oil  in  the  later  stages  of  the 
disease.  Treatment  by  digital  manipulation  of  the 
vesicle  by  the  way  of  the  rectum  is  contraindicated. 
From  time  to  time,  however,  the  finger  may  be  intro- 
duced in  order  to  note  the  progress  of  the  disease.  All 
local  forms  of  treatment  directed  toward  the  bladder  or 
urethra  are  distinctly  injurious.  In  the  later  stages  of 
the  disease,  after  the  contents  of  the  vesicle  are  dis- 
charged along  the  ejaculatory  duct,  marked  signs  of 
urethral  irritation  may  appear,  for  the  relief  of  which 
the  internal  administration  of  balsamics  and  antiblennor- 
rhagics  is  often  useful. 

The  first  stage  of  the  disease,  the  end  of  which  is 
marked  by  the  free  discharge  of  pus  along  the  ejacu- 
latory duct  into  the  prostatic  urethra,  is  usually  of  from 
ten  days  to  two  weeks  duration,  after  which  time  it 
generally  requires  two  weeks  for  the  inflammation  to 
subside ;  in  other  words,  rest  in  bed  for  a  month  may 
be  requisite,  the  patient  being  allowed  on  his  feet  only 


TREA  TMENT  AND  PR  0  GNOSIS.  1 47 

when  the  rectal  touch  fails  longer  to  show  evidences  of 
vesicular  inflammation. 

Numerous  surgeons  in  dealing  with  the  management 
of  acute  seminal  vesiculitis  have  advocated  as  routine 
treatment  opening  the  affected  sac  and  draining  off  the 
accumulation  of  pus  by  means  of  a  perineal  incision. 
Reich,  of  Vienna  {Journal  des  Praticiens,  May  13, 
1894),  even  reports  that  Von  Dittel  has  gone  so  far  in 
one  of  these  cases  as  to  incise  the  entire  length  of  the 
sac.  The  author  in  his  experience  has  yet  to  see  one  of 
these  cases  which  has  required  perineal  drainage  in 
order  to  give  vent  to  the  purulent  vesicle  contents,  and 
he  holds  ablation  of  a  vesicle  under  these  conditions  to 
be  a  surgical  mutilation  which  is  wholly  unwarranted. 
Attention  has  already  been  called  to  the  fact  that  oc- 
clusion-cysts in  connection  with  the  seminal  vesicles 
either  do  not  exist,  or,  if  they  occur,  that  they  must  be 
of  extreme  rarity,  as  no  anatomical  demonstration  of 
this  condition  has  ever  as  yet  been  reported.  When 
acute  collections  of  pus  become  sufficiently  voluminous 
to  distend  the  vesicle  to  a  certain  extent,  enough  ma- 
terial finds  vent  out  of  the  sac  along  the  ejaculatory 
duct  to  relieve  the  pressure  within,  and  to  prevent  a 
rupture,  associated  with  an  acute  burrowing  of  pus, 
from  taking  place.  It  is  not  denied  that  there  may  exist 
a  condition  of  acute  seminal  vesiculitis,  complicated 
with  an  acute  purulent  perivesiculitis,  which  may  re- 
quire and  demand  speedy  drainage  by  means  of  a  free 
incision  through  the  perineum ;  but  such  a  severe  con- 
dition of  affairs  is  happily  infrequent. 

The  prognosis  of  acute  seminal  vesiculitis  is  usually 
good,  provided  the  individual  affected  is  not  strumous 
and  the  methods  of  treatment  herein  advocated  are 
followed   out.      There   are   usually   no    symptoms    left 


148  MALE  SEXUAL  ORGANS. 

behind  to  serve  as  reminders,  and  no  remaining  evi- 
dences in  connection  with  the  vesicle  sufficient  to  enable 
a  surgeon  to  mark  it  as  the  seat  of  a  preceding  inflam- 
mation. If,  however,  the  disease  is  treated  without 
insisting  upon  absolute  and  prolonged  rest  in  bed,  then 
the  prognosis  is  bad,  most  such  cases  becoming  chronic 
and  complicated  with  an  extensive  peri  vesiculitis.  A 
chronic  case  of  this  description  is  liable  to  yield  slowly 
to  treatment,  and  to  be  especially  rebellious. 

Treatment  of  Subacute  and  Chronic  Seminal  Vesiculitis. 
The  treatment  advocated  for  this  form  of  disease  con- 
sists in  an  attempt  to  aid  the  mechanism  of  ejaculation, 
which  has  been  more  or  less  interfered  with  by  reason 
of  the  existing  pathological  processes,  and  at  the  same 
time  to  eradicate  these  processes  or  so  to  minimize  them 
that  they  will  be  no  longer  capable  of  exerting  an  injuri- 
ous influence  on  the  sexual  function.  The  mechanism  of 
ejaculation  has  already  been  studied  in  considering  the 
physiology  of  the  parts  and  the  manner  in  which  patho- 
logical changes,  with  reference  not  only  to  the  contents 
of  the  vesicle,  but  also  to  the  walls  of  the  sac  and  the 
surrounding  tissues,  interfere  with  ejaculation,  has  like- 
wise received  attention.  Based  upon  these  physiological 
and  pathological  features,  and  after  a  careful  anatomical 
investigation,  the  author  has  already  presented  to  the 
profession  his  treatment  of  stripping  the  diseased  vesi- 
cles by  means  of  the  forefinger  introduced  into  the 
rectum.  Two  articles — one  entitled  "  Seminal  Vesicu- 
litis" {Journal  of  Cutaneous  and  Genito- Urinary  Dis- 
eases, New  York,  September,  1893),  and  the  other 
"Persistent  Urethral  Discharges  Dependent  on  Sub- 
acute or  Chronic  Seminal  Vesiculitis"  (Journal  of  Cu- 
taneous and  Genito-  Urinary  Diseases,  New  York,  June 
and  July,  1894) — have  been  published  by  him,  in  which 


TEE  A  TILES  T  AXD  PR  0  GNOSIS.  149 

this  treatment  has  been  carefully  and  fully  considered. 
The  author  first  began  in  1891  to  make  a  systematic 
trial  of  the  method  of  treatment  which  will  be  shortly 
described.  In  the  first  article,  which  was  prepared  and 
read  at  the  ISTew  York  Academy  of  Medicine  in  the 
spring  of  1893,  the  treatment  was  still  spoken  of  as 
somewhat  experimental.  In  the  next,  written  a  year 
afterward,  the  results  derived  from  the  treatment  since 
the  writing;  of  the  first  article  had  been  so  striking  and 
beneficial  that  it  was  not  felt  necessary  to,  as  it  were, 
apologize  for  the  methods  employed  on  the  ground  that 
they  were  experimental.  And  now,  as  the  result  of  a 
riper  experience  and  of  a  much  wider  acquaintance  with 
these  conditions,  the  author  is  prepared  to  advocate 
strongly  his  treatment  for  subacute  and  chronic  vesi- 
culitis as  curative  in  most  instances,  if  properly  em- 
ployed, and  also  as  being  the  only  method  heretofore 
advanced  which  has  been  of  any  positive  value  in  this 
connection.  The  writer  does  not  claim  that  the  idea 
embodied  in  the  treatment  of  stripping  the  vesicles  is 
original  with  himself.  He  does,  however,  claim  the 
credit  of  putting  it  to  practical  account,  and  of  de- 
veloping therefrom  a  system  and  method  of  treatment 
which  at  his  own  and  at  the  hands  of  numerous  others 
has  proved  to  be  of  special  merit  and  value.  It  was 
from  Dr.  E.  L.  Keyes,  and  from  some  experiments 
undertaken  by  that  gentleman  in  1887  and  1888,  that 
the  writer  derived  his  ideas  in  this  connection.  Dr. 
Keyes's  theory  was  that  certain  cases  among  those 
classed  as  spermatorrhoea,  especially  those  in  which 
there  was  a  complaint  of  seminal  losses  following  strain- 
ing at  stool,  might  be  benefited  by  systematic  pressure 
applied  at  regular  intervals  upon  the  vesicles  by  means 
of  some  appliance  introduced  into  the  rectum,  the  object 


150 


MALE  SEXUAL  ORGANS. 


being  to  restore  the  muscular  tonicity  of  the  vesicles  by 
not  allowing  them  to  remain  in  an  overdistended  con- 
dition. The  following  mention  of  these  experiments 
was  made  by  the  author  in  his  article  already  referred 
to  on  seminal  vesiculitis  : 


Fig.  20. 


Keyes's  rubber  bag  for  pressure  on  the  vesicles. 
Fig.  21. 


The  same  instrument  when  dilated. 

"Acting  on  this  idea,  Dr.  E.  L.  Keyes,  a  few  years 
ago,  designed  and  had  constructed  a  rubber  colpeur- 
ynter  containing  two  lateral  air-chambers.  The  instru- 
ment was  pushed  well  into  the  rectum,  and  then  inflated 
and  drawn  firmly  forward,  the  expectation  being  that 
the   distended   air-chambers    pressing   on    the   vesicles 


TEE  A  T3IENT  AND  PR  0  GNOSIS. 


151 


would  squeeze  out  their  contents  along  the  ejaculatory 
ducts  and  into  the  urethra.  Figs.  20  and  21  show 
patterns  of  this  instrument,  both  designed  by  Dr. 
Keyes.  Fig.  22  has  a  handle,  in  order  that  the  traction 
and  pressure  may  be  the  better  regulated. 

Fig.  22. 


The  same  instrument  with  the  hard-rubber  shaft  attachment. 


"  These  instruments  accomplished  their  purpose  to  a 
certain  extent ;  they  were  deficient,  however,  in  that  not 
only  their  introduction  and  manipulation  were  painful 
and  objectionable  to  the  patient,  but  also  and  more  im- 
portant the  pressure  of  the  air-chambers  on  the  vesicles 
could  not  be  well  regulated  or  adjusted.  They  were, 
therefore,  abandoned  and  the  forefinger  employed." 

Since  writing  the  article  just  referred  to,  however, 
the  writer  has  discovered  that  Trousseau  held  ideas  on 
this  subject  very  similar  to  those  advanced  by  Keyes. 
This  French  author,  in  his  work  entitled  Glinique  Med- 
icate de  V Hotel-Dim  de  Paris,  second  edition,  vol.  ii., 
Paris,  1865,  devotes  a  chapter  to  seminal  losses.  This 
chapter  is  of  such  interest  that  it  has  seemed  well  to 
make  certain  quotations  from  it.  Trousseau  held  that 
spermatorrhoea  could  be  divided  into  two  classes — (1) 
where  it  was  dependent  on  an  excess  of  contractility  of 
the  seminal  vesicles,  and  (2)  where  it  was   dependent 


152  MALE  SEXUAL  ORGANS. 

on  an  atony  of  the  ejaculatory  ducts.  For  the  first 
class  of  cases  the  treatment  of  Lallemand,  which  con- 
sisted of  touching-  the  verumontanum  with  caustic,  was 
approved  of.  For  the  second  class,  however,  Lalle- 
mand's  method  was  held  to  be  of  no  avail,  and  treat- 
ment by  means  of  continuous  pressure  on  the  atonic 
ejaculatory  ducts  was  advised.  In  speaking  of  the 
history  of  this  latter  treatment,  Trousseau  states :  "In 
1825,  while  an  interne  at  the  Maison  de  Sante  de  Char- 
enton,  Dr.  Bleynie,  who  was  attached  to  that  institution, 
spoke  to  me  concerning  one  of  his  patients  suffering 
from  impotence,  who,  having  found  a  certain  Parisian 
charlatan,  had  been  cured  by  means  of  a  procedure 
which  necessitated  his  wearing  in  his  rectum  a  knob  of 
wood."  Ten  }rears  after  this,  Trousseau,  bearing  in 
mind  the  idea  derived  from  Bleynie,  put  it  to  a  practical 
test  in  an  aggravated  case  of  sexual  derangement.  He 
shaped  a  piece  of  wood  so  that  it  resembled  a  speculum, 
introduced  it  into  the  rectum,  and  maintained  it  there 
for  fifteen  days  by  means  of  strappings.  Improvement 
was  marked  at  the  end  of  five  days,  and  at  the  end  of 
fifteen  days  a  cure  was  reported.  After  his  first  suc- 
cessful case  the  author  endeavored  to  find  the  reason  for 
the  satisfactory  result,  and  then  it  was  that  he  advanced 
his  theory  of  atony  and  distention  of  the  ejaculatory 
ducts,  to  cure  which  continuous  rectal  pressure  was 
essential.  Acting  on  this  idea,  Trousseau  invented  an 
apparatus  consisting  of  an  ivory  or  hard-rubber  cone 
attached  to  a  T-bandage,  which  was  in  turn  secured 
about  the  waist.  The  cone  was  of  such  length  and 
shape  that  on  being  inserted  into  the  rectum  it  pressed 
on  the  seminal  vesicles  and  prostate.  An  exact  descrip- 
tion of  this  instrument  and  of  its  method  of  appliance 
is  given ;  but  these  are  details  which  it  is  unnecessary 


TBEA  TMENT  AND  PR  0  GNOSIS.  153 

to  repeat.  With  this  improved  appliance  farther  suc- 
cesses were  recorded. 

As  has  been  said,  the  technique  of  stripping  diseased 
vesicles  has  been  fully  described  in  the  author's  two 
articles  on  the  subject,  so  that  in  this  connection  little 
is  necessary  further  than  the  incorporation  of  these  de- 
scriptions with  whatever  modifications  and  changes  a 
greater  experience  may  have  suggested. 

"  To  accomplish  the  treatment,  the  patient  presenting 
himself  with  a  full  bladder  should,  while  standing  with 
his  knees  straight,  bend  the  body  forward  at  right- 
angles.  Then  the  operator  should  introduce  the  fore- 
finger of  one  hand  well  into  the  rectum,  the  fist  of  the 
other  hand  exercising  firm  counter-pressure  over  the 
pubes.  By  these  means  the  end  of  the  forefinger  will  in 
all  ordinary  cases  reach  well  beyond  the  posterior  margin 
of  the  prostate.  The  bodies  of  the  vesicles  can  thus 
be  detected,  one  on  each  side  beyond  the  posterior 
prostatic  border.  (Only  the  lower  half  of  the  body  of 
the  vesicle  can  be  felt  ordinarily  by  the  finger,  the  rest 
being  beyond  reach.)  After  the  forefinger  has  been  so 
introduced  firm  pressure  should  be  made  by  its  tip  on 
the  body  of  the  vesicle  to  be  treated  as  far  back  as  it 
is  possible  to  reach.  Then  the  finger-tip,  the  pressure 
being  maintained,  should  be  slowly  and  firmly  drawn 
forward  along  the  line  of  the  vesicle.  The  manoeuvre 
is  aided  by  the  counter-pressure  over  the  pubes  with 
the  free  hand.  This  process  may  be  repeated  several 
times  in  connection  with  each  vesicle.  In  this  manner 
some  of  the  vesicular  contents,  provided  the  sac  be 
diseased  and  distended,  can  be  pressed  out  along  its 
ejaculatory  duct  and  into  the  prostatic  sinus. 

"  As  has  been  stated,  the  stripping  should  be  done 
on  a  full  bladder,  and  after  the  manipulation  the  urine 


154  MALE  SEXUAL  ORGANS. 

should  be  voided  in  order  that  the  surgeon  may  see  how 
much  has  been  expressed.  This  treatment  should  be 
repeated  not  oftener  than  once  in  four  days,  and  in  most 
cases  under  active  treatment  as  often  as  once  a  week. 
If  it  is  done  too  frequently,  or  too  severe  pressure  Avith 
the  forefinger  is  employed,  acute  symptoms  may  be 
stirred  up  which  may  leave  the  patient  worse  off  appar- 
ently than  before  treatment  was  commenced,  besides  at 
times  causing  an  acute  epididymitis.'' 

In  his  first  article  the  author  says  :  "I  have  had  the 
misfortune  to  cause  such  an  acute  attack  in  two  of  my 
earlier  cases  from  too  vigorous  and  too  frequent  treat- 
ments. One  of  the  cases  was  too  acute  in  the  first 
place  to  be  suitable  for  this  form  of  treatment,  and  in 
the  second  case  I  failed  to  stop  the  treatment  when 
acute  symptoms  began  to  reappear.  The  chief  signs 
of  a  rekindling  of  acute  symptoms  are  the  increased 
tenderness  in  the  vesicular  region  which  the  patient 
experiences  on  manipulation,  and  the  appearance  of  the 
fluid  pressed  out  of  the  vesicle,  free  pus  appearing, 
which  renders  the  whole  specimen  turbid  if  the  part  is 
threatened  by  an  acute  inflammation.  Another  accident 
which  may  occur  in  very  chronic  cases  if  too  severe  pres- 
sure is  employed,  and  probably  in  some  such  instances 
where  the  appropriate  amount  is  employed,  is  hemor- 
rhage into  the  vesicular  sac.  Such  hemorrhage  may  be 
severe,  causing  great  distention  and  much  pain.  This 
accident  occurred  in  one  of  my  chronic  cases,  probably 
from  too  severe  pressure  in  trying  to  squeeze  out  a  mass 
of  very  inspissated  material.  It  will  thus  be  seen  that 
this  treatment  must  be  used  with  much  care  to  avoid 
oftentimes  disagreeable  accidents.  These  accidents  will 
probably  be  sufficiently  frequent  in  the  hands  of  some 
to  cause  them  to  decry  vigorously  this  form  of  treat- 


TREA  TMENT  AND  PR 0 GXOSIS.  155 

merit,  and  to  condemn  it  altogether.  In  the  cases, 
however,  which  progress  favorably  the  tenderness  of  the 
vesicles  gradually  disappears,  the  amount  of  material 
squeezed  out  each  time  becomes  less,  and  finally  nil,  the 
vesicles  themselves  feel  less  prominent  to  the  touch,  and 
eventually  largely  escape  detection,  and  the  patient  is 
cured.  In  numerous  cases  this  vesicular  pressure  is  all 
that  is  required  to  effect  a  cure.  In  others,  however, 
supplementary  treatment  may  be  indicated.  If  general 
anemia  and  lack  of  nerve-force  are  associated  condi- 
tions, then  mix  vomica,  cod-liver  oil,  iron,  etc.,  may  be 
of  great  value,  together  with  light  outdoor  exercise 
and  a  generous  diet.  In  all  cases  where  any  vesical 
fermentation  coexists,  and  in  some  cases  where  the  ex- 
pulsion force  of  the  bladder  seems  sluggish,  vesical 
lavage  immediately  after  the  squeezing  of  the  vesicles 
may  be  of  value,  the  bladder  being  filled  with  an  anti- 
septic stimulating  substance — a  solution  of  corrosive 
sublimate,  from  1  in  12,000  to  1  in  20,000,  often  serving 
the  purpose.  The  patient  is  then  directed  to  void  this 
solution  in  the  natural  manner,  thus  bathing  the  deep 
urethral  portion  of  the  canal.  Deep  urethral  injections 
of  stimulating  or  astringent  substances,  always  in  cases 
which  are  at  all  acute,  and  in  most  chronic  cases,  are 
injurious,  aggravating  the  existing  symptoms  frequently 
to  a  marked  degree.  Sometimes,  however,  in  the  con- 
valescent stage  of  subacute  or  chronic  cases,  where  for 
a  considerable  period  the  vesicles  have  been  stripped  of 
their  accumulations,  and  where  the  muscular  tone  has 
been  partially  re-established,  then  such  deep  injections 
may  be  used  with  advantage.  In  rare  instances  deep 
stimulating  injections  give  relief  in  very  chronic  cases 
unassociated  with  rectal  pressure.  Sounds  in  most 
cases    are   distinctly  injurious.     In   a  few  chronic   in- 


MALE  SEXUAL 

stances,  however,  they  may  be  of  seme  temporary 
benefit  in  relaying  symptoms.  Sexual  intercourse 
shoudi:  be  '  -  :hi"  ire i  while  these  cases  are  under  active 
treatment.  When  convalescence  is  fully  established. 
coitus  once  or  perhaps  twice  a  week  sometimes  seems 
t<:  exerois  n  favorable  influence  b j  stimnlating  the  con- 
fer of  the  vesicle.  It  should  always  be 
mo  '---  iowever:  and.  if  it  taxes  the  strength  of  the 

vesicle  too  much,  it  should  be  speedily  abandoned." 
The  author  still  adhere-  in  the  main  to  these  ideas 
uotec  :"■  m  his  first  paper.  As  a  supplementary  treat- 
ment in  the  convalescent  stage,  however,  he  is  at  present 
more  adverse  to  employing-  deep  urethral  injections  than 
formerly,  preference  now  being  given  to  vesical  lavage. 
administered  in  the  manner  described ;  and  in  those 
cases  where  corrosive  sublimate  solutions  do  not  ap- 
parently produce  sufficient  stimulation,  nitrate  of  silver 
solutions  in  the  strength  of  from  1  to  3  grains  to  the 
pint  of  water  are  recommended.  He  also  employs  cod- 
liver  oil  more  extensively  than  heretofore,  it  having 
been  found  especially  efficacious  in  hastening  the  ab- 
sorption of  chronic  indurations  in  those  cases  where 
such  improvement  is  slow,  although  there  be  no  sus- 
picion of  a  tubercular  tendency.  Also,  as  regards 
sexual  intercourse  in  convalescence,  something  further 
can  be  said.  If  such  is  to  be  allowed,  the  patient 
should  be  directed  to  report  for  examination  after  the 
accomplishment  of  the  act.  If.  then,  an  examination 
shows  the  vesicles  to  be  firm,  and  if  little  or  nothing 
can  be  stripped  from  therm  in  all  probability  coitus  will 
be  productive  of  good.  If.  on  the  other  hand,  however, 
an  examination  -hows  the  sacs  to  be  distended  and 
tender,  and  if  considerable  material  can  be  stripped 
from  therm  then  coitus  will   be  productive  of  harm,  and 


TREATMENT  AND  PBOGNO  SIS.  157 

should  be  prohibited  until  convalescence  be  further 
established. 

In  his  second  article  the  author  makes  the  following 
remarks  on  treatment,  which  are  in  a  measure  supple- 
mentary to  the  remarks  in  the  first  article : 

"During  the  active  stage  of  treatment  patients  should 
be  seen  once  in  every  five  to  seven  days.  The  active 
stage  of  treatment  lasts  all  the  way  from  a  month  to 
six  weeks,  in  the  most  favorable  cases  to  eight  or  nine 
months,  and  possibly  longer  in  severe  and  chronic  ones. 
During  the  active  stage  of  treatment,  in  some  cases 
where  there  is  a  tendency  to  an  inflammatory  reaction. 
it  may  be  beneficial  to  suspend  treatment  for  a  month 
or  six  weeks. 

"After  resolution  in  the  vesicles  has  been  sufficiently 
established — i.e.,  after  the  muscular  tonus  has  been  re- 
stored— it  is  still  well,  as  a  precautionary  measure,  to 
examine  these  organs  at  least  once  a  month  for  a  period 
of  from  four  to  six  months  in  order  to  make  certain  that 
they  do  not  tend  to  relapse  into  their  former  state,  thus 
rendering  a  return  of  the  discharge  possible.  The 
peculiar  mode  of  treatment  adopted  in  these  cases. 
which  consists  of  stripping  the  diseased  vesicles  of  their 
contents  by  means  of  the  forefinger  in  the  rectum,  has 
been  fully  described  in  my  article  on  seminal  vesiculitis, 
reference  to  which  has  already  been  made. 

"  As.  however,  some  confusion  seems  still  to  exist  in 
the  professional  mind  regarding  this  point,  it  has  -  .-  mied 
well  at  the  present  time  to  make  further  remarks  on 
this  subject.  In  the  first  place,  there  has  been  a  ten- 
dency to  confound  this  treatment  with  that  of  the  so- 
called  'prostatic  massage."  which  form  of  treatment  has 
been  advocated  off  and  on  for  a  number  of  years,  in  a 
rather  random  manner,  by  a  few  Continental  writers, 


158  MALE  SEXUAL  ORGANS. 

chiefly  Russian,  for  certain  vague  prostatic  conditions, 
mainly  neuralgias,  such  as  may  persist  after  the  sub- 
sidence of  inflammatory  conditions,  and  in  old  men  to 
reduce  chronic  prostatic  hypertrophy,  the  object  being 
to  improve  the  circulation  in  the  parts  with  the  hope  of 
promoting  absorption.  In  a  good  percentage  of  cases 
where  I  have  delegated  this  stripping  of  the  vesicles  to 
others,  and  in  which,  after  an  apparently  sufficient  in- 
terval, no  improvement  took  place,  I  found  that  the 
attending  surgeon  had  not  grasped  the  idea  of  stripping 
the  vesicles,  but  had  simply  massaged  the  prostatic 
region.  By  so  doing  little  or  none  of  the  inflammatory 
vesicular  material  was  pressed  out,  but  rather  churned 
up,  as  it  were.  Consequently  the  vesicular  contents, 
instead  of  being  reduced,  were  more  apt  to  be  increased 
by  reason  of  the  disturbance  produced,  and  thus  often- 
times the  condition  of  the  patient  was  aggravated  rather 
than  relieved. 

"In  a  number  of  these  cases,  with  the  consent  of  the 
attending  surgeon,  I  subsequently  undertook  the  treat- 
ment, with  the  result  of  speedily  relieving  the  symp- 
toms. In  all  such  cases  the  patients  remarked  that  my 
manipulations  produced  sensations  entirely  different  from 
those  they  had  previously  experienced  during  their 
former  treatment. 

'•  Then,  again,  a  number  of  surgeons  have  declared  to 
me  that  such  treatment  could  be  successfully  executed 
only  by  those  who  happened  to  have  a  long  forefinger, 
and  consequently  an  extensive  reach.  This  is  the  same 
argument  which  one  hears  so  often  advanced  against 
the  short-armed  man  in  the  boxing-match.  Still,  if  the 
short-armed  man  has  only  the  requisite  skill,  it  is  seen 
that  he  has  no  difficulty  in  reaching  all  the  vulnerable 
parts  of  his  long-armed  antagonist.     I  take  it  that  the 


TBEA  TMENT  AND  PR 0  GNOSIS.  1 59 

forefinger  of  most  adults  is  long  enough.  In  fact,  the 
real  obstacle  to  success  does  not  lie  in  the  length  of  the 
forefinger,  but  in  the  ability  of  the  operator  to  overcome 
the  natural  resistance  of  the  perineal  muscles.  When 
a  case  is  first  treated  this  muscular  resistance  is  liable 
to  be  very  marked.  As,  however,  the  patient  becomes 
by  degrees  accustomed  to  the  manipulations,  and  as  the 
vesicular  tenderness  decreases,  this  element  of  muscular 
resistance  diminishes.  On  this  account  it  is  always  well 
with  a  new  case  to  be  as  gentle  as  possible  in  executing 
treatment,  otherwise  what  is  simply  a  disagreeable  sen- 
sation may  be  looked  upon  as  an  ordeal. 

"  If  a  patient  continues  in  this  latter  mental  state,  the 
muscular  tension  is  always  intensified  and  manipula- 
tions may  be  very  difficult.  To  overcome  this  muscular 
resistance,  firm  pressure  with  the  closed  fist,  minus  the 
extended  forefinger,  against  the  perineum  is  necessary. 
In  some  thick-set,  rigid  individuals  the  perineal  pres- 
sure required  may  be  very  considerable,  since  in  such 
instances  counter-pressure  on  the  hypogastrium  with 
the  other  hand  accomplishes  but  little. 

"  In  such  cases  the  muscular  effort  required  to  enable 
the  forefinger  to  perform  the  necessary  stripping  may  be 
greater  than  an  operator  who  is  not  physically  fairly 
robust  can  command.  As  an  aid  in  making  perineal 
pressure  where  much  resistance  is  encountered,  I  have 
found  that  the  knee  corresponding  to  the  arm  used  in 
manipulating  can  be  made  to  play  an  important  aux- 
iliary role  in  pushing  against  the  elbow.  In  order  to 
carry  out  this  manoeuvre  a  chair  is  drawn  up  behind 
the  patient  as  he  stands  with  his  body  bent  forward,  in 
what  I  have  been  accustomed  to  term  the  'leap-frog' 
position,  and  ready  for  the  treatment.  Then  the  foot  of 
the  operator  corresponding  to  the  hand  to  be  aided  is 


160  MALE  SEXUAL  ORGANS. 

placed  in  the  chair,  thus  bringing  the  knee  up  to  the 
level  of  the  elbow.  By  this  arrangement  the  muscles 
of  the  thigh  and  leg,  as  well  as  of  the  arm  and  shoulder, 
all  working  together,  can  furnish  pressure  sufficient  to 
overcome  the  resistance  of  the  most  rigid  perineum.  It 
is  only  occasionally  that  such  extensive  muscular  efforts 
are  called  for.  In  weakly,  loose-fibred  individuals  little 
or  no  perineal  pressure  is  required  to  reach  the  vesicles, 
or  even,  if  need  be,  much  further.  In  fact,  in  such 
cases  with  a  little  counter-abdominal  pressure  one  can 
easily  engage  the  tip  of  the  forefinger  in  the  sigmoid 
flexure." 

The  author,  as  is  seen,  recommends  that  the  patient 
presenting  himself  for  treatment  shall  have  a  full  blad- 
der. This  is  for  two  reasons.  In  the  first  place,  when 
the  bladder  is  full  the  rectal  finger  can  more  easily 
reach  the  vesicles ;  and  in  the  second  place,  by  having 
urine  in  the  bladder,  which  can  be  passed  after  the 
treatment,  the  surgeon  by  inspecting  it  each  time  is 
able  to  compare  the  varying  amounts  and  qualities  of 
the  expressed  fluids.  The  point  has  also  been  empha- 
sized, that  the  manipulations  should  not  be  too  severe, 
nor  the  pressure  exerted  by  the  finger  too  great,  in  the 
early  stages  of  treatment.  After,  however,  all  tender- 
ness has  disappeared,  then  in  many  cases  heavy  pres- 
sure on  the  vesicles  can  be  well  borne  and  is  productive 
of  much  good. 

The  stripping  process  is  productive  of  good  results 
not  only  by  reason  of  its  expressing  pathological  ma- 
terial from  the  cavity  of  the  vesicle,  but  also  by  stimu- 
lating, in  connection  with  the  vesical  walls  and  surround- 
ing tissues,  a  reabsorption  of  inflammatory  congestions 
and  exudations.  In  this  latter  respect  it  acts  in  a 
manner    similar   to   a    sound   on  a  granular   infiltrated 


TEE  A  TMENT  AND  PRO  GNOSIS.  161 

urethra.  Each  stripping  stirs  up  a  fresh  engorgement 
of  the  chronically  inflamed  organ,  and  after  the  sub- 
sidence of  each  of  these  temporary  engorgements  the 
parts  are  found  to  be  somewhat  more  elastic,  pliable, 
and  natural  than  before  it.  J^o  stripping  should  ever 
be  repeated  until  the  engorgement  effects  of  the  pre- 
ceding treatment  have  disappeared,  and  this  ordinarily 
takes,  as  has  been  stated,  from  four  days  to  a  week. 

In  all  of  these  cases  during  the  early  stages  of  treat- 
ment, and  in  some  of  them  throughout  the  period  of 
active  treatment,  the  testicles  should  be  so  supported 
by  a  well-fitting  suspensory  bandage  that  all  tension  is 
removed  from  the  spermatic  cords. 

For  the  successful  treatment  of  seminal  vesiculitis 
the  forefinger  of  the  genito-urinary  surgeon  requires  as 
much  education  in  the  rectal  feel  as  does  that  of  a 
gynaecologist  in  the  vaginal  feel,  in  order  not  only  to 
appreciate  variations  or  differences  in  regard  to  diseased 
conditions,  but  also  to  make  sure  of  detecting  existing 
disease.  A  short  time  since  the  author  attempted  to 
demonstrate  to  a  practitioner  unaccustomed  to  the  rectal 
feel  an  extremely  well-marked  case  of  chronic  vesicular 
disease.  The  gentleman,  however,  declared  that  he 
could  appreciate  nothing  by  his  feel ;  and,  as  numerous 
practitioners  rarely  make  a  digital  rectal  exploration,  it 
is  probable  that  such  an  experience  under  similar  con- 
ditions may  not  be  of  rare  occurrence  with  many.  As 
an  evidence  of  the  difficulty  that  some  experience  in 
attempting  this  treatment  of  stripping  the  vesicles  are 
the  remarks  made  regarding  it  by  R.  W.  Taylor,  of 
New  York,  in  an  unpublished  paper  read  at  the  Annual 
Meeting  of  the  American  Association  of  Genito-Urinary 
Surgeons  at  Washington,  D.  C,  May  31,  1894.     Taylor 

apparently  found  it  no  easy  matter  in  many  cases  to 

n 


162  MALE  SEXUAL   ORGANS. 

reach  the  vesicles  with  his  finger,  and  also  to  determine 
thereby  the  existing  state  of  affairs.  "With  sufficient 
practice,  however,  careful  attention  being  paid  to  the 
technique  herein  described,  the  author  sees  no  reason 
why  most  surgeons  should  no  be  able  successfully  to 
accomplish  the  treatment.  Taylor  also,  in  his  paper 
just  referred  to,  was  inclined  to  think  the  treatment 
herein  advocated  of  stripping  the  vesicles  an  impossible 
process  owing  to  the  interior  structure  of  these  organs, 
they  being,  according  to  him,  made  up  of  blind-ended 
tubes,  extendino;  in  all  sorts  of  directions.  From  this 
hypothesis  Taylor  argued  that  the  pressure  exerted  by 
the  tip  of  the  forefinger  from  above  downward  along 
the  general  course  of  the  vesicle,  since  it  did  not  cor- 
respond with  the  tortuous  directions  represented  by  the 
blind-ended  tubes,  could  not  force  out  the  contents  of 
the  vesicle.  The  fact  that  there  is,  as  seen  in  Fig.  7, 
a  main  pyriform-shaped  cavity  to  the  vesicle,  which  ex- 
tends down  to  and  is  continuous  with  the  ejaculatory 
duct,  the  directions  of  both  corresponding  exactly  with 
the  direction  of  the  outside  contour  of  the  vesicle,  evi- 
dently escaped  that  gentleman's  notice.  His  argument, 
therefore,  was  founded  on  a  false  assumption. 

In  the  chapter  on  Anatomy  the  author  has  mentioned 
the  fact  that  if  one  on  endeavoring  to  explore  the  in- 
terior of  a  vesicle  first  of  all  opens  the  diverging  canals 
at  the  top  of  the  organ  instead  of  slitting  up  the  cavity 
from  below — from  the  region  of  the  ejaculatory  duct — 
much  confusion  will  result  regarding  the  contour  of  the 
interior  cavity ;  and  this  is  probably  why  Taylor  thought 
that  for  anatomical  reasons  stripping  a  vesicle  was  im- 
possible. As  far  as  stripping  out  the  contents  of  the 
diverging  canals,  which  communicate  with  the  main 
cavity  of  the  vesicle,  by  the  process  herein  advocated 


TREA  TMENT  AND  PR  0 GNOSIS.  163 

is  concerned,  Taylor's  argument  may  be  to  some  extent 
correct.  It  is  not  claimed,  however,  that  the  finger-tip 
can  reach  to  the  very  top  of  the  vesicle,  except  in  oc- 
casional instances,  as  would  be  required  in  order  to  strip 
the  canals.  In  fact,  the  question  of  whether  or  not 
these  structures  can  be  stripped  does  not  bear  in  the 
least  on  the  treatment  of  stripping  the  vesicle  as  ad- 
vocated in  this  work,  since  this  treatment  has  reference 
only  to  the  main  cavity  of  the  vesicle. 

On  the  erroneous  idea  also  that  the  ampulla  of  Henle 
(the  enlarged  cavity  of  the  vas  deferens)  is  directly 
connected  with  and  continuous  with  the  corresponding 
ejaculatory  duct,  when  in  reality  it  connects  with  the 
cavity  of  the  vesicle  by  a  sphincter  or  valve-like  open- 
ing, some  investigators  have  thought  that  much  of  the 
material  forced  out  of  the  ejaculatory  ducts  by  the 
stripping  process  came  directly  from  the  ampullae,  and 
that  these  cavities  rather  than  those  of  the  vesicles  were 
the  important  features  in  this  treatment. 

In  this  connection  some  clinical  investigations  by 
Posner,  of  Berlin  ( Verliandl.  d.  Kongresses  f.  innere 
Medizin,  Wiesbaden,  1889),  on  the  diagnosis  and  treat- 
ment of  chronic  prostatitis  are  worthy  of  notice.  M. 
Krotoszyner,  a  student  of  Posner's  {Int.  Cntrl.fur  d. 
Phys.  u.  Path.  d.  Ham.  u.  Sex.-Org.,  1893,  p.  363,  and 
Journal  of  the  American  Medical  Association,  Chicago, 
July  31,  1894),  also  appears  in  two  articles  based  on 
Posner's  ideas  as  set  forth  in  his  original  paper.  These 
papers  have  but  very  recently  come  to  the  attention  of 
the  writer.  Posner  holds  that  certain  cases  of  posterior 
urethritis  are  really  dependent  on  a  chronic  prostatitis, 
which  in  many,  if  not  most,  instances  involves  the 
ejaculatory  ducts.  In  order  to  determine  this  condition 
the  so-called  "  expression  test"  is  advocated.     This  test 


164  MALE  SEXUAL  ORGANS. 

is  as  follows :  The  patient  starting  with  a  full  bladder 
urinates  a  part  of  the  vesical  contents  into  two  glasses 
as  usual,  but  reserves  a  portion  of  urine  still  in  the 
bladder.  The  finger  is  then  introduced  into  the  rectum 
and  made  to  exert  firm  pressure  against  the  prostate. 
The  third  portion  of  urine  is  after  this  passed.  If 
chronic  prostatitis  so-called  exists,  then  the  evidence  of 
this  condition  will  be  found  in  the  last  portion  of  urine, 
which  will  be  seen  on  comparison  with  the  middle  speci- 
men to  be  milky  or  cloudy,  and  oftentimes  to  contain 
shreds  in  greater  number  than  appear  in  the  other  two 
specimens.  It  is  also  noted  that  spermatozoa  are,  as  a 
rule,  found  in  these  expressed  specimens,  which  indicate 
the  existence  of  a  chronic  prostatitis.  Many  of  these 
cases  are  cured,  according  to  Posner,  by  repetitions  of 
this  digital  prostatic  expression. 

It  seems  to  the  writer  probable  that  these  cases, 
classed  by  Posner  as  chronic  prostatitis,  are  really  cases 
of  seminal  vesiculitis,  since  the  expressed  fluid  is  said 
to  contain,  as  a  rule,  spermatozoa,  and  since,  as  is 
stated,  the  ejaculatory  ducts  are  in  almost  all  instances 
involved  in  the  inflammation.  It  further  seems  prob- 
able that  "the  digital  expression  of  the  prostate''  is 
curative  only  in  so  far  as  it  happens  to  free  the  ejacu- 
latory ducts  from  inflammatory  material. 

Koltz,  of  New  York  ("Endoscopic  Studies,"  New 
York  Medical  Journal,  January  26,  1895),  has  made  the 
attempt  in  one  instance  to  treat  a  purulent  gonorrhceal 
seminal  vesiculitis  by  injections  of  a  few  drops  of  a 
2J  per  cent,  solution  of  nitrate  of  silver  into  the  ure- 
thral opening  of  the  ejaculatory  duct,  a  specially  con- 
structed Pravaz's  syringe  with  a  long  canula  being 
used.  An  endoscopic  tube  was  first  introduced  and 
the  mouth  of  the  ejaculatory  duct  located  by  means  of 


TEE  A  TMENT  AND  PE  0  GNOSIS.  165 

the  pus  which  constantly  exuded  from  it.  Then  the 
nozzle  of  the  syringe  was  introduced  through  the  en- 
doscopic tube  and  its  end,  after  considerable  difficulty, 
engaged  in  the  opening  of  the  duct.  Several  such 
injections  were  made  at  intervals,  and  the  urethral 
symptoms,  which  were  a  feature  in  this  case,  improved. 
A  severe  grade  of  epididymitis,  however,  was  appar- 
ently induced  thereby,  and  the  treatment  had  to  be 
suspended.  Such  treatment,  in  like  manner  as  strong 
deep  urethral  injections  of  nitrate  of  silver  under  similar 
conditions,  will,  in  the  author's  opinion,  prove  itself 
injurious  rather  than  beneficial  in  curing  seminal  vesic- 
ulitis, though  it  may  temporarily  subdue  attendant 
urethral  symptoms. 

The  prognosis  of  subacute  and  chronic  seminal  vesic- 
ulitis is  in  most  cases  good,  at  least  as  far  as  regards 
curing  the  subjective  symptoms.  Some  cases  are,  how- 
ever, very  slow  in  showing  marked  improvement ;  and 
should  the  individual  so  affected  be  of  an  impatient 
disposition,  he  will  probably  abandon  systematic  treat- 
ment before  the  favorable  effects  show  themselves.  In- 
stances where  there  is  marked  perivesicular  induration 
or  extensive  inflammatory  infiltration  into  the  walls  of 
the  sac  are  liable  to  belong  to  this  slow  class.  Chronic 
vesiculitis  in  elderly  men,  associated  with  senile  hyper- 
trophy of  the  prostate,  is  probably  little  benefited  by 
treatment.  The  age  of  the  patient  is  a  very  important 
element  in  the  prognosis.  What  are  apparently  the 
severest  grades  of  disease  generally  yield  satisfactorily 
to  treatment  in  those  under  thirty  years  of  age.  The 
results  also  in  those  between  thirty  and  forty  years  old, 
although  slower  than  in  those  more  youthful,  especially 
if  the  disease  is  of  very  long  standing,  are  still,  as  a 
rule,  favorable.     With   patients    over  forty  years    old, 


166  MALE  SEXUAL  OB  GANS. 

however,  a  guarded  prognosis  should  always  be  given. 
Disease  in  those  of  a  good  physique  yields  quicker  than 
in  those  who  are  generally  feeble  and  frail.  Seminal 
vesiculitis,  associated  with  suppuration  in  connection 
with  the  interior  of  the  vesicle,  is  slower  in  getting  well 
than  the  non-suppurative  forms. 

Treatment  of  Tubercular  Seminal  Vesiculitis.  Rarely, 
as  has  been  mentioned,  the  tubercular  process  in  this 
connection  may  take  an  acute  form.  In  such  instances 
the  treatment  during  such  a  stage  should  be  much  the 
same  as  that  advocated  for  the  simple  acute  inflam- 
mation, except  that  considerable  alcoholic  stimulation 
would  be  of  benefit,  as  would  also  cod-liver  oil  in  some 
easily  assimilated  form,  provided,  of  course,  the  stomach 
can  tolerate  the  drug.  Acute  tubercular  trouble  in  this 
connection,  unless  it  extends  and  involves  the  bladder 
and  testicle,  gradually  becomes  chronic.  Tubercular 
inflammation  of  the  vesicles,  however,  is  generally  sub- 
acute or  chronic. 

In  the  management  of  these  subacute  and  chronic 
tubercular  conditions  of  the  vesicles  the  main  point  lies 
in  promptly  distinguishing  them  from  the  correspond- 
ing non-tubercular  inflammations.  For  if  one  starts  in 
vigorously  to  strip  vesicles  so  affected  a  marked  inflam- 
matory reaction  is  liable  to  result,  which  leaves  the 
patient  worse  off"  than  before  resorting  to  treatment. 
In  this  connection  it  may  be  well  to  quote  the  following 
passages  from  the  author's  second  published  article  on 
this  subject  {Journal  of  Cutaneous  and  Genito-Urinary 
Diseases,  June  and  July,  1894)  : 

"I  wish  also  to  impress  on  the  professional  mind  the 
frequency  of  tubercular  inflammation  of  the  vesicles, 
and  to  warn  all  in  these  cases  to  exercise  the  greatest 
care  in  attempting  digital  rectal  treatment,  lest  the  con- 


TEE  A  TMENT  AND  PE  0  GNOSIS.  167 

dition  of  the  patient  be  aggravated  rather  than  palliated. 
The  practised  finger  will  soon  learn  to  detect  this  con- 
dition, either  at  the  first  examination  or  very  shortly 
after  commencing  a  course  of  strappings,  as  the  result 
of  the  inflammatory  reaction  produced  by  the  manipu- 
lations." 

And  also :  "  In  this  form  of  inflammation  the  parts 
resent  the  manipulations,  unless,  indeed,  they  be  most 
gentle ;  and  even  then  it  is  a  question  if  this  form  of 
treatment  is  beneficial.  If  the  tubercular  condition  is 
not  diagnosed  at  first,  the  manner  in  which  the  vesicles 
when  so  involved  resent  the  ordinary  manipulations  by 
becoming  more  tender  and  indurated,  thus  aggravating 
the  urethral  symptoms,  speedily  renders  the  correct 
diagnosis  apparent." 

The  most  efficacious  means  of  treating  these  cases 
consists  in  measures  of  a  general  character  intended  to 
combat  the  tubercular  diathesis,  such  as  climatic  in- 
fluences, hygiene,  generous  diet,  etc.  Cod-liver  oil,  if 
it  can  be  tolerated,  will  prove  of  great  value.  If  vesical 
or  urethral  inflammatory  symptoms  coexist,  as  is  fre- 
quently the  case,  no  local  methods  of  treatment  should 
be  directed  toward  them,  at  least  in  the  early  part  of  the 
treatment.  Such  conditions  are  generally  best  treated 
by  ordering  the  individual  to  drink  freely  of  some 
diuretic  spring  water.  Occasionally,  where  a  painful 
cystitis  coexists,  an  anodyne  may  be  necessary.  The 
finger  should  not  be  introduced  into  the  rectum  during 
the  early  treatment,  except  for  diagnostic  purposes  and 
to  watch  the  progress  of  the  disease.  If  the  patient 
can  be  gotten  into  a  fine  physical  condition  as  the  result 
of  general  methods  of  treatment,  then,  in  most  in- 
stances, the  vesiculitis  disappears  along  with  the  advent 
of  the  general   improvement.     If,  however,  the  effects 


168  MALE  SEXUAL  ORGANS. 

of  the  vesiculitis  persist  in  spite  of  the  general  im- 
provement, as  may  be  the  case  especially  where  the 
inflammation  has  to  a  considerable  extent  impaired  the 
muscular  tone  of  the  sacs,  then  gentle  and  judicious 
strippings  may  be  of  great  benefit,  and  may  serve  to 
complete  the  cure.  If  likewise  a  little  vesical  inflam- 
mation or  a  urethral  discharge  also  persists,  then  some 
mild  local  measures  may  be  tried ;  but  not,  however, 
until  it  is  seen  that  the  gentle  strippings  fail  to  cure  the 
urinary  symptoms.  Where  local  urinary  treatment  is 
called  for  under  these  circumstances,  vesical  lavage  of 
corrosive  sublimate  solutions,  in  the  strength  of  from 
one-fifth  to  one-third  of  a  grain  in  ten  ounces  of  hot 
water,  is  recommended,  given  once  in  three  or  four  days. 
A  soft  catheter  is  passed  and  as  much  of  the  fluid  as 
can  be  comfortably  contained  is  injected.  Then  the 
catheter  is  withdrawn  and  the  injected  fluid  urinated  in 
the  natural  manner.  In  this  way  the  whole  tract  is 
medicated.  Nitrate  of  silver  solutions  are  too  stimu- 
lating for  these  cases.  If,  however,  the  patient  does 
not  yield  to  general  measures  of  treatment,  owing  ap- 
parently to  the  disease  in  his  vesicles,  and  if  the  disease 
is  confined  largely,  at  least,  to  one  or  both  of  these 
organs,  then  extirpation  of  one  or  both  of  them,  as  the 
case  may  be,  is  a  procedure  which  is  not  only  proper, 
but  may  be  demanded. 

Operative  Procedures.  The  operative  procedures  which 
have  been  performed  in  connection  with  the  vesicles  are, 
(1)  aspiration,  (2)  incision  and  drainage,  and  (3)  ex- 
tirpation. 

Aspiration.  Jordan  Lloyd,  of  Birmingham  {British 
Medical  Journal,  April  20,  1889,  and  London  Lancet, 
October  31,  1891),  has  aspirated  vesicles  when  the 
seat   of    suppuration,    and    advocates    this    procedure. 


TREATMENT  AND  PROGNOSIS.  169 

The  needle  is  made  to  enter  the  cavity  of  the  dis- 
tended sac  through  the  perineal  tissue,  a  finger  in  the 
rectum  acting  as  a  guide  to  it  as  it  is  pushed  through 
the  perineum.  Cases,  however,  which  get  well  from 
such  a  simple  operation  must  be  those  in  which  the 
suppurative  process  is  wholly  confined  to  the  cavity  of 
the  sac,  the  perivesicular  tissues  remaining  undisturbed. 
Cases  of  this  variety  when  acute  generally,  as  has  been 
seen,  recover  completely  as  the  result  of  non-operative 
methods  of  treatment,  a  very  small  proportion  only  of 
them  becoming  chronic.  The  subacute  and  chronic 
cases  of  this  variety  yield  to  the  stripping  treatment. 
It  therefore  seems  to  the  author  that  aspiration  is  a  form 
of  treatment  which  can  be  abandoned. 

Incision  and  Drainage.  Lloyd  also,  in  the  two 
articles  just  referred  to,  besides  aspiration  advocates 
perineal  incision  into  the  vesicle  (the  technique  of  which 
is  much  the  same  as  that  of  aspiration),  in  purulent 
conditions,  and  the  establishment  of  drainage.  Since 
then  a  number  of  others  have  adopted  this  method. 
Where,  however,  an  operator  desires  to  lay  open  the 
cavity  of  the  vesicle,  and  not  merely  to  incise  it,  a 
more  formidable  operation,  associated  with  considerable 
dissection,  is  necessary.  The  various  dissections  which 
may  be  employed  under  these  circumstances  will  be 
considered  under  the  heading  of  excision.  Reich  (Jour- 
nal des  Praticiens,  May  23,  1894)  reports  a  case  of  this 
description  in  which  Von  Dittel  operated.  The  Von 
Dittel  incision  was  made  and  the  rectum  was  displaced 
to  the  right.  It  was  found  necessary  also  to  resect  the 
coccyx.  The  sac  was  then  opened  and  tamponed  with 
iodoform -gauze. 

With  the  introduction  of  the  stripping  treatment  in 
subacute  and  chronic  simple  inflammations,  and  of  the 


170  MALE  SEXUAL  ORGANS. 

treatment  herein  advocated  for  acute  ones,  the  necessity 
for  incising  the  seminal  vesicles  will  be  very  much 
lessened.  In  very  acute  conditions,  however,  compli- 
cated with  perivesicular  suppuration,  treatment  more 
vigorous  than  that  usually  employed  would  be  de- 
manded ;  and,  under  such  conditions,  free  incision  and 
drainage  would  be  called  for,  in  which  case  the  author 
is  of  the  opinion  that  one  of  the  special  dissections, 
such  as  are  employed  in  extirpation,  would  be  far  better 
than  simply  plunging  a  long-bladed  knife  through  the 
perineum  to  the  seat  of  the  disease,  as  Lloyd  advocates. 
In  most  of  these  cases  the  author  would  recommend  the 
procedure  of  Zuckerkandl,  although  in  some  instances, 
where  the  suppuration  outside  the  sac  seems  to  be  very 
extensive,  one  of  the  procedures  consisting  of  a  still 
freer  incision  might  be  more  advisable.  Likewise  in 
some  cases  of  chronic  purulent  seminal  vesiculitis  com- 
plicated with  purulent  perivesiculitis,  a  free  incision 
into  and,  probably  better  still,  through  the  sac,  in  order 
the  more  perfectly  to  drain  the  surrounding  tissues, 
might  be  called  for,  although  in  such  extreme  instances 
complete  extirpation  of  the  sac  would  probably  be 
better  surgery.  Tubercular  vesicles  not  amenable  to 
the  conservative  methods  herein  advocated  for  these 
cases  might  be  treated  by  incision  and  drainage ;  but, 
as  has  been  found  in  the  surgery  of  tubercular  kidneys, 
it  is  here  likewise  probable  that  total  extirpation  is 
the  better  general  method  of  treatment,  provided,  of 
course,  that  by  so  doing  the  principal  or  most  distress- 
ing focus  of  disease  may  be  eliminated.  Another  indi- 
cation, rare  to  be  sure,  demanding  free  incision  into  the 
cavity  of  the  vesicle  is  calculi  too  large  to  be  stripped 
out  along  the  ejaculatory  ducts.  The  author's  case  of 
this  nature,  which  will  be  related  in  the  last  chapter, 


TREATMENT  AND  PROGNOSIS.  171 

would  have  required  this  operation  had  the  concretion 
been  any  larger.  Polypoid  growths  also  serving  to 
obstruct  the  outlet  of  the  vesicle  could  be  removed  in 
this  manner.  A  case  of  this  description  has,  however, 
not  as  yet  been  recorded. 

Extirpation.  It  is  to  Kraske  that  much  credit  is  due 
in  connection  with  many  of  the  operations  which  have 
later  been  undertaken  with  the  object  of  extirpating  the 
vesicles.  To  be  sure,  Kraske  planned  his  procedure 
with  the  idea  of  removing  cancer  involving  the  upper 
portion  of  the  rectum.  Still,  it  was  the  possibilities 
presented  by  his  plan  of  procedure  that  led  many 
surgeons  to  study  it  as  a  means  of  attacking  disease 
in  connection  with  other  and  deeper  seated  organs  of 
the  pelvis.  It  also  acted  as  an  impetus  in  attracting 
surgical  attention  to  this  locality.  Kraske  published 
his  procedure  in  1885  (k'Zur  Exstirpation  hochsitzender 
Mastdarm  Krebse,"  Verliandl.  d.  Deutsch  Geschellscli.  f. 
Chir.  Berl,  1885,  xiv.,  part  ii.,  pp.  464-474).  It  con- 
sisted of  a  cut  beginning  near  the  posterior  superior 
spine  of  the  ilium,  on  the  left  side  for  operations  on  the 
rectum  (on  the  right  for  operations  on  other  pelvic 
structures),  and  extending  along  the  border  of  the 
sacrum.  At  the  region  of  the  coccyx  it  turned  in 
somewhat.  The  cut  did  not  extend  much  beyond  the 
coccyx.  The  enucleation  of  the  coccyx  and  the  resec- 
tion of  the  corresponding  sacral  wing  up  to  the  third 
foramen  were  included  in  the  operation.  This  procedure 
was  shortly  after  its  introduction  utilized  by  gynae- 
cologists for  extirpation  under  certain  conditions  of  the 
uterus.  In  1889,  O.  Zuckerkandl  ("  Ueber  die  peri- 
neale  Blosslegung  der  Prostata  und  der  hinteren  Blasen- 
wand,"  Wien.  med.  Presse,  1889,  xxx.  857-902),  as  a 
result  of  his    anatomical    investigations,  proposed  the 


172 


MALE  SEXUAL  ORGANS. 


following  procedure,  intended  to  expose  the  prostate, 
seminal  vesicles,  and  base  of  the  bladder  for  operative 
purposes :  A  concave  incision  is  made  across  the  peri- 
neum from  one  tuber  ischii  to  the  other,  the  concavity 
looking  toward  the  rectum.  (Fig.  23.)  The  perineal 
muscles  are  then  cut  through,  the  portions  of  the  le- 
vator ani  arising  from  the  pubes  divided,  and  the  rectum 
drawn  backward.     Fig.  1  in  the  chapter  on  Anatomy 

Fig.  23. 


Zuckerkandl's  incision. 


represents  the  deeper  steps  in  this  dissection  perfectly, 
so  no  further  explanation  of  it  is  here  necessary.  As 
seen,  however,  in  Fig.  1,  the  space  that  this  dissection 
allows  for  operative  manipulation  in  connection  with  the 
seminal  vesicles  is  very  small.  The  best  that  it  aifords 
is  a  limited  exposure  of  the  lower  portion  of  the  vesicle, 
through  which  the  organ  has  to  be  drawn  in  case  of 
extirpation,  which  procedure  might  be  attended  with 
much  difficulty,  and  would   perhaps    be  impossible,  if 


TEE  A  TMENT  AND  PE  0  GNOSIS.  173 

firm  perivesicular  adhesions  existed,  such,  for  instance, 
as  are  represented  in  Plates  VII.  and  VIII.  If  the 
organ  to  be  attacked,  however,  is  not  especially  adherent, 
this  procedure  is  of  value  and  perfectly  feasible,  as  shown 
by  the  number  of  successful  extirpations  which  have 
been  accomplished  by  means  of  its  employment. 

In  1890,  E.  Ullmann  (Centralblatt  f.  Chir.,  Leipzig, 
February  22,  1890),  adopting  the  theoretical  procedure 
advocated  by  Zuckerkandl,  was  the  first  one  to  extir- 
pate the  seminal  vesicles.  He  successfully  removed 
both  these  organs,  which  were  tubercular,  from  a  seven- 
teen year  old  boy.  The  patient  got  well,  but  a  perineal 
fistula  persisted,  which,  however,  did  not  give  passage 
to  urine. 

In  the  same  year,  1890,  Von  Dittel  ( Wiener  klin. 
Wochenschrift,  May  1  and  8,  1890)  devised  and  pub- 
lished his  method  of  lateral  or  bilateral  prostatectomy, 
which  method  he  asserted  could  also  be  appropriately 
used  for  the  extirpation  of  seminal  vesicles.  The 
method  is  as  follows :  A  catheter  is  tied  in  so  that  the 
urethra  may  be  easily  appreciated  and  shielded  from 
injury  in  operating.  For  like  reasons  the  rectum  is 
stuffed  out  with  gauze,  the  ends  of  which  are  left  hang- 
ing out  so  that  the  whole  can  be  easily  removed.  The 
patient  is  placed  lying  on  his  belly,  with  his  legs  hang- 
ing down.  A  cut  is  then  made  extending  from  the  tip 
of  the  coccyx  down  in  the  middle  line  almost  to  the 
rectum.  It  then  deviates  to  the  right  or  left,  as  the 
case  may  be,  just  avoiding  the  rectum,  making  a  half- 
moon-shaped  curve  around  that  opening,  and  terminat- 
ing in  the  middle  of  the  perineum.  In  completing  the 
dissection  the  rectum  is  pushed  upward  and  to  one  side. 
If  more  room  is  needed,  the  coccyx  can  be  removed  and 
the  lower  end  of  the  incision,  instead  of  terminating  in 


174 


MALE  SEXUAL  ORGANS. 


the  middle  of  the  perineum,  can  be  continued  laterally 
and  upward  to  the  tuber  ischii,  thus  combining  the 
Zuckerkandl  incision  with  that  of  Von  Dittel.  Such  a 
combination  has  been  called  the  Zuckerkandl- Von  Dittel 
procedure  for  extirpating  the  seminal  vesicles.  It  affords 
much  more  space  for  operative  manipulation  than  the 
exclusive  employment  of  either  of  these  methods,  and 
is  consequently  of  much  value.  Fig.  24  represents 
Von  Dittel's  incision. 

Fig.  24. 


Von  Dittel's  incision. 


In  1891,  Roux  (La  Semaine  Medicate,,  Paris,  April 
8,  1891)  reported  the  removal  on  two  occasions  of  tuber- 
cular seminal  vesicles.  As  the  method  he  adopts  is 
practically  the  same  as  that  of  Zuckerkandl,  it  is  not 
necessary  to  describe  it  further.  He  makes,  however, 
the  following  suggestion  in  regard  to  the  technique, 
which  seems  to  be  clever :  After  a  vesicle  has  been 
exposed  a  finger  is  introduced  into  the  rectum  and 
utilized  to  press  the  organ  down  into  the  wound,  where 


TREA  TMENT  AND  PR 0 GNOSIS.  175 

it  can  be  more  easily  grasped  and  drawn  forward  pre- 
paratory to  being  excised. 

In  the  same  year  also  "Villeneuve  {La  Semaine  Medi- 
cate, Paris,  September  23, 1891)  reported  the  removal  of 
a  seminal  vesicle  through  the  inguinal  canal  by  the  fol- 
lowing method  :  He  opens  first  the  tunica  vaginalis  and 
works  his  way  upward,  following  the  cord  to  the  in- 
guinal canal,  the  tissues  surrounding  it  being  freely 
incised.  Then  the  inguinal  canal  is  laid  open  down  to, 
and  if  necessary  even  through,  the  internal  ring.  This 
accomplished,  traction  is  exerted  on  the  cord  in  a  manner 
similar  to  that  on  the  round  ligament  in  Alexander's 
operation.  In  this  manner  the  vesicle  is  brought  into 
view  and  excised.  The  serious  objections  to  this 
method,  namely,  its  uncertainty,  since  in  most  instances 
requiring  extirpation  traction  on  the  cord  does  not  bring 
the  vesicle  into  view  (because  the  organ  is  bound  down 
firmly  by  adhesions,  and  because  the  cord  being  likewise 
inflamed,  and  consequently  brittle,  breaks  easily),  and 
also  the  liability  to  hernia  which  it  occasions,  have  been 
sufficient  to  prevent  its  adoption  by  others,  although 
Biingner  {Deutsche  med.  Wocliensclirift,  April  19, 1894), 
in  striving  to  effect  what  he  calls  high  castration,  ad- 
vocates stripping  up  the  cord  as  far  as  possible,  and 
then  exerting  slow  traction  on  the  portion  remaining 
still  unexposed  until  it  breaks  somewhere  along  the 
higher  part.  The  author  in  his  article  on  "  Seminal  Ves- 
iculitis "  {Journal  of  Cutaneous  and  Genito-  Urinary  Dis- 
eases, New  York,  September,  1893),  in  making  mention 
of  "Villeneuve's  method,  states :  "I  tried  this  procedure 
it  one  case;  the  cord,  however,  was  brittle,  probably 
from  tubercular  infiltration,  and  broke  on  being  sub- 
jected to  moderate  tension  long  before  the  vesicle  had 
been  brought  into  view." 


176 


MALE  SEXUAL  ORGANS. 


In  1893,  Rydygier  ("  Eine  neue  Methode  der  tempo- 
raren  Resektion  des  Kreuzsteissbeines  behufs  Freile- 
gung  der  Beckenorgane,"  Centralbl.  f.  Chir.,  Leipzig, 
1893,  xx.  1-5)  presented  the  following  modification  of 
Kraske's  method :  He  commences  his  incision  just 
behind  the  posterior  superior  spine  of  the  ileum,  and 
extends  it  obliquely  downward  along  the  border  of  the 
sacrum,  always  keeping,  however,  about  half  an  inch 

Fig.  25. 


Rydygier's  incision. 


from  the  border  of  that  bone,  so  that  its  margin  may  be 
well  covered  by  skin  even  after  the  retraction  of  the 
edge  of  the  wound  occurs.  The  lower  portion  of  the 
cut  is  carried  downward  in  the  middle  line  from  the  tip 
of  the  coccyx  toward  the  rectum  as  far  as  may  be 
deemed  necessary.  A  transverse  cut  is  then  made 
inward  across  the  sacrum  just  below  the  third  sacral 
foramen,  which  is  about  two  inches  from  the  junction 
of  the  sacrum  and  the  coccyx.     The  sacrum  is  exposed 


TREATMENT  AND  PROGNOSIS.  177 

by  this  transverse  cut  and  divided  with  chisel  and 
hammer.  The  lower  large  triangular  flap  is  then  raised 
without  difficulty  and  bent  back,  thus  affording  much 
exposure  of  the  pelvic  contents.  After  the  completion 
of  the  operation  the  flap  of  bone  and  skin  is  replaced. 
(Fig.  25.)  Rydygier,  in  presenting  this  operation,  simply 
had  extirpation  of  the  upper  portion  of  the  rectum  in 
view,  and  consequently  advocates  that  the  cut  be  made 
on  the  left  side.  He  asserts  that  there  is  no  necessity 
of  suturing  together  the  fragments  of  the  sacrum,  and 
that  necrosis  is  not  liable  to  occur ;  also  that  no  im- 
portant nerves  need  be  divided  in  the  operation.  The 
wound  is  packed  with  iodoform-gauze  and  left  open 
in  its  lower  portion.  Schede  {Deutsche  med.  Wbchen- 
schrift,  Leipzig,  February  15,  1894)  reports  having 
extirpated  the  seminal  vesicle  successfully  on  two  oc- 
casions, the  method  employed  being  that  advocated  by 
Rydygier.  Schede  prefers  this  method  to  that  of  Von 
Dittel  on  the  ground  that  it  is  easier  to  perform,  that 
it  affords  the  operator  greater  space,  and  that  there  is 
no  trouble  from  a  bulging  of  the  rectum  into  the  field 
of  operation.  The  same  author  (Deutsche  med.  Wochen- 
schrift,  June  28,  1894),  in  another  communication  on 
this  subject,  in  which  he  further  recommends  the  em- 
ployment of  the  method  of  Rydygier  for  extirpation  of 
the  seminal  vesicle,  mentions  that  Sick  has  successfully 
performed  this  operation  by  combining  the  transverse 
sacral  cut,  such  as  Rydygier  has  advocated,  with  Von 
Dittel's  method.  Weir  (New  York  Medical  Hecord, 
August  11,  1894)  reports  the  removal  of  both  seminal 
vesicles  successfully,  the  method  of  Zuckerkandl  being 
employed. 

Just  what  operative  procedure  out  of  all  those  con- 
sidered,   exclusive   of  Villeneuve's,   is    the   best,  it   is 

12 


178  MALE  SEXUAL  ORGANS. 

impossible  to  say.  Each  one  has  its  favorable  and 
unfavorable  features ;  and  it  is  probable  that  the  best 
surgeon  will  not  confine  himself  strictly  to  any  one  of 
them,  but  will  adapt  the  exact  method  to  be  employed 
in  each  case  to  the  clinical  features  of  the  disease  to  be 
attacked  and  to  the  physical  development  of  the  patient. 
Thus,  if  the  patient  be  very  fat  and  thick-set,  and  if 
the  vesicle  to  be  attacked  be  bound  down  by  firm 
adhesions,  then  the  method  of  Rydygier,  or  some 
feature  of  it,  combined  perhaps  more  or  less  with  Von 
Dittel's,  would  seem  advisable.  If,  on  the  other  hand, 
the  patient  be  thin,  and  if  the  vesicles  be  at  all  movable, 
then  Zuckerkandl's,  Yon  Dittel's,  or  a  combination  of 
the  two  methods  might  be  best.  One  strong  point  in 
favor  of  the  Zuckerkandl  method  is  that  it  exposes  to 
an  equal  degree  both  vesicles — a  feature  which  does  not 
pertain  to  any  of  the  others.  If,  therefore,  double  ex- 
tirpation is  required,  this  cut  would  probably  be  called 
for,  combined  perhaps  with  that  of  Von  Dittel,  and,  if 
necessary,  also  with  that,  more  or  less  complete,  of 
Rydygier  (or  Kraske).  One  would  hardly  advocate  a 
double  Rydygier  or  a  double  Von  Dittel  operation  in 
case  it  was  desirable  to  remove  both  vesicles. 

Most,  if  not  all,  the  reported  extirpations  were  under- 
taken for  the  removal  of  localized  tubercular  disease. 
The  author,  as  has  been  stated,  much  prefers,  as  a  rule, 
conservative  methods  in  regard  to  cases  of  this  nature, 
and  would  advocate  extirpation  only  in  instances  where 
the  hygienic  and  tonic  methods  have  failed  or  bid  fair 
to  fail.  If  malignant  disease  can  be  detected  while  still 
confined  to  this  part,  extirpation  would,  of  course,  be 
called  for,  in  which  case  Rydygier's  method  would  be 
advised  as  probably  giving  the  best  opportunity  for 
careful  investigation  and  thorough  extirpation.     Puru- 


TREA  TMENT  AND  PR 0 GNOSIS.  179 

lent  perivesiculitis  and  disorganized  conditions  of  the 
vesicle,  such  as  might  result  from  such  inflammations, 
or  from  calculi,  from  benign  growths  and  from  trau- 
matisms, might  also  be  causes  sufficient  to  demand 
extirpation  of  the  vesicle. 


CHAPTER   VII. 

ILLUSTRATIVE   INSTANCES. 

To  the  casual  reader  the  present  chapter,  consisting, 
as  it  does,  of  the  recital  in  considerable  detail  of  numer- 
ous cases  illustrating  facts  mentioned  in  the  body  of  the 
book,  may  seem  unnecessarily  prolonged,  and  conse- 
quently somewhat  prosy ;  but  to  the  practitioner  inter- 
ested in  the  subject  it  is  not  thought  that  it  will  be 
found  faulty  in  this  respect. 

Owing  to  the  newness  of  the  subject,  and  to  the  con- 
sequent absence  in  medical  literature  of  such  clinical 
reports,  the  author  has  considered  it  necessary  to  put 
these  cases  on  record,  in  order  not  only  to  show  in  a 
clinical  way  their  frequency  and  the  value  of  the  study 
represented  in  this  work,  but  also  to  aid  those  wishing 
thoroughly  to  master  the  subject. 

CASE  I.  Acute  Gonorrhceal  Seminal  Vesiculitis.  A  typical 
case.  A  young  man,  aged  twenty-three  years,  contracted 
his  first  gonorrhoea  about  a  month  before  reporting  for 
treatment.  The  attack  had  been  light,  and  had  been 
treated  chiefly  by  means  of  anterior  astringent  injec- 
tions. When  he  first  presented  himself  he  had  posterior 
urethritis,  accompanied  by  painful  micturition  every  few 
hours  day  and  night.  A  few  light  deep  urethral  appli- 
cations were  given  and  the  case  improved.  Shortly 
afterward,  apparently  as  a  result  of  active  exercise,  he 
was  attacked  by  a  sudden  pain  in  the  left  suprapubic 


ILL  USTRA  TIVE  INSTANCES.  181 

region,  radiating  down  into  the  testicle  and  upward 
toward  the  hypogastrium.  There  ivas  also  marked 
tenderness  in  the  left  hypogastric  region.  This  attack 
of  pain  was  associated  with  a  chill  and  a  considerable 
rise  of  temperature.  Rectal  examination  showed  great 
tenderness  over  the  left  vesicle.  In  a  few  days  the 
vesicle  swelled  very  much,  and  the  swelling  and  oedema 
quickly  extended  into  the  surrounding  tissues,  so  that 
the  finger  in  the  rectum  encountered  a  mass  in  the 
region  of  the  left  vesicle  the  size  almost  of  a  goose's 
eg-o-.  This  inflamed  mass  extended  down  to  and  seemed 
to  be  blended  with  the  prostate,  which  was  also  inflamed 
and  swollen.  The  mass  was  so  tender  that  the  gentlest 
manipulation  caused  great  pain.  Urination,  although 
now  not  so  urgent  as  formerly,  was  very  painful  and 
was  rather  difficult,  the  stream  being  fine  and  ejected 
spasmodically.  The  left  spermatic  cord  also  became 
inflamed  and  swollen.  The  epidermis,  however,  was 
never  affected.  The  patient  was  in  bed  almost  four 
weeks.  Continuous  fever  lasted  over  two  weeks.  He 
was  not  allowed  out  of  bed  till  all  the  tenderness  and 
most  of  the  swelling  in  connection  with  the  vesicle  had 
disappeared.  During  the  fever  the  urine  was  perfectly 
clear  and  there  was  no  discharge.  When  convalescence 
commenced  the  urine  became  loaded  with  pus,  a  profuse 
discharge  appeared,  urination  became  less  and  less 
painful,  and  the  size  of  the  stream  larger.  The  treat- 
ment employed  was  that  recommended  for  this  condition. 
The  recovery  was  complete. 

CASE  II.  Acute  Gonorrhoeal  Seminal  Vesiculitis  High 
fever  and  chills.  Few  symptoms  pointing-  toward  the  vesicle 
at  first.  A  young  man,  aged  thirty  years,  first  called 
the  writer  in  on  the  occasion  of  a  severe  chill.     He  was 


182  MALE  SEXUAL  ORGANS. 

at  the  time  suffering  from  his  second  attack  of  gonor- 
rhoea, which  he  had  already  had  about  six  weeks. 
Shortly  before  this  he  had  thought  himself  almost  well ; 
but,  as  the  result  apparently  of  sexual  excitement,  his 
urethral  discharge  had  returned,  associated  with  urgent 
urination  and  severe  pain  in  the  perineal  region  on  erec- 
tion. In  the  urine  there  were  large  purulent  clumps 
from  the  deep  urethra  and  considerable  free  pus.  The 
rectal  feel  showed  the  prostate  to  be  rigidly  contracted, 
though  but  little  swollen.  The  vesicular  region  was 
tender,  especially  on  the  right  side,  but  not  tumefied. 
The  patient  was  kept  in  bed  for  two  days,  a  light  ano- 
dyne given,  together  with  diuretics  and  balsamics.  On 
the  day  after  leaving  his  bed,  while  jumping  off  a 
swiftly  moving  horse-car,  he  felt  a  sudden  severe  pain 
in  his  perineum,  and  shortly  afterward  he  experienced  a 
severe  chill.  He  went  to  bed  again,  and  on  the  next 
day  all  the  evidences  of  an  acute  inflammation  of  the 
right  seminal  vesicle  appeared.  There  was  great  pain 
in  the  right  hypogastric  region,  and  the  tenderness  was 
so  marked  that  the  slightest  touch  could  not  be  toler- 
ated.  Urination  became  painful  and  frequent.  For 
several  days  the  fever  ranged  between  102°  and  104°. 
At  the  very  first  of  this  second  attack  painful  erections 
were  present,  but  as  the  fever  became  pronounced  they 
disappeared.  There  were  shooting  pains  into  the  tes- 
ticle, and  after  several  days  that  organ  swelled  moder- 
ately. The  urine  as  the  fever  rose  became  perfectly 
clear,  with  here  and  there  a  linear  shred.  At  the  end  of 
ten  days  pus  began  to  appear  in  the  urine,  and  the  acute 
symptoms  and  fever  began  to  decrease  in  a  marked 
degree.  At  the  end  of  two  and  a  half  weeks  the  urine 
was  loaded  with  pus  and  the  swelling  of  the  vesicle  had 
begun  to  decrease  rapidly.    It  was  five  full  weeks  before 


ILLUSTRATIVE  INSTANCES.  183 

the  vesiculitis  had  subsided  so  that  the  patient  could 
with  safety  leave  his  bed.  At  that  time,  however,  all 
his  symptoms  had  disappeared,  his  urine  was  clear,  and 
he  has  remained  perfectly  well  ever  since.  The  treat- 
ment such  as  has  been  recommended  for  acute  condi- 
tions was  prescribed  in  this  case.  In  this  case  it  is 
probable  that  the  first  chill  was  premonitory  of  the 
threatened  acute  attack;  and  had  this  case  been  kept 
in  bed  longer  at  first  he  probably  would  have  avoided 
his  subsequent  trouble. 

CASE  III.  Acute  Seminal  Vesiculitis  in  a  Tubercular  Sub- 
ject. An  instance  where  a  subacute  tubercular  condition 
of  the  vesicle  was  rendered  acute  by  gonorrhoeal  infection. 
The  case  in  question,  aged  forty-three  years,  had  been 
tubercular  from  childhood.  He  had  anchylosis  of  one 
hip-joint,  and  the  scarred  remains  of  numerous  sinuses 
connecting  with  the  joint.  He  had  also  had  minor 
tubercular  outbreaks  in  connection  with  other  parts. 
He  had  had  gonorrhoea  twice  in  early  life.  For  the  last 
few  years  he  had  been  troubled  with  sexual  cravings, 
and  had  consequently  indulged  freely,  without,  however, 
being;  able  to  get  marked  satisfaction.  When  first  seen 
a  fresh  gonorrhceal  contagion  was  just  beginning  to 
manifest  itself — the  meatus  being  puffy,  sore,  and  glued 
with  a  straw-colored  discharge.  Gonococci  were  found. 
Although  the  gonorrhceal  infection  was  confined  at  this 
stage  to  the  region  of  the  meatus,  still  it  was  thought 
well  to  note  the  condition  at  this  time  of  the  seminal 
vesicles,  owing  to  the  symptoms  of  sexual  craving  which 
pointed  in  that  direction.  Both  vesicles  were  found 
somewhat  thickened  and  indurated,  although  not  tender. 
The  gonorrhceal  infection  progressed  rapidly,  and  the 
urethral  symptoms  caused  by  it  were  severe.     His  uri- 


184  MALE  SEXUAL  ORGANS. 

nation  at  the  end  of  ten  days  became  very  frequent  and 
urgent,  and  much  pain  was  complained  of  at  defecation. 
Rectal  digital  exploration  now  showed  both  vesicles, 
especially  the  right,  to  be  very  tumefied  and  tender, 
although  the  tenderness  was  not  so  marked  as  in  Cases 
I.  and  II.  Slight  pressure  on  the  right  side  caused  a 
free  purulent  flow  from  the  meatus,  and  in  this  flow 
there  were  streaks  of  blood  and  numerous  spermatozoa. 
Fever  was  present,  but  was  not  a  marked  feature  as  in 
Cases  I.  and  II.  Hypogastric  tenderness  also  was  not 
so  marked.  The  right  epididymis  in  a  few  days  became 
involved  and  an  acute  hydrocele  appeared,  which  soon 
became  purulent,  necessitating  an  incision.  The  patient 
was  kept  in  bed  for  about  four  weeks.  By  the  time, 
however,  resolution  had  taken  place  in  the  epididymis 
and  the  tunica  vaginalis,  the  urine  had  cleared  up  and 
the  urinary  act  become  natural.  Examination  of  the 
vesicles  showed  them  to  be  again  in  apparently  the  same 
condition  as  at  the  first  examination.  Since  convales- 
cence the  patient  has  reported  that  he  is  all  right. 

The  author  was  rather  suprised  with  the  termination 
of  this  case,  especially  with  the  quick  resolution,  as 
he  had  thought  the  acute  vesiculitis  might  lead  in 
such  an  instance  to  a  chronic  and  extensive  suppurative 
process. 

CASE  IV.  Subacute  Seminal  Vesiculitis  brought  on  by 
Mental  Strain  and  Overwork.  Frequent  urination  associated 
with  a  burning-  sensation.  Severe  pains  over  the  pubes. 
Frequent  erections.  Difficulty  in  starting-  his  stream  at 
times.  The  patient,  aged  thirty-five  years,  had  for  a 
number  of  years  been  overworked,  and  had  devoted  but 
a  few  hours  each  night  to  sleep.  He  was  married,  and, 
although  frequently  his  erections  were  so  persistent  as 


ILLUSTRATIVE  INSTANCES.  185 

to  be  troublesome,  still  little  relief  or  satisfaction  was 
experienced  from  sexual  intercourse.  He  had  never  had 
gonorrhoea.  His  urination  was  frequent  and  associated 
with  burning  sensations  extending  along  the  urethra. 
He  also  had  a  pain  located  above  the  pubes,  which  at 
times  was  very  severe.  Occasionally  in  the  morning  on 
arising  he  experienced  great  difficulty  in  starting  his 
stream.  His  urine  was  clear.  Rectal  digital  feel  showed 
the  vesicular  region  to  be  very  tender.  The  vesicles, 
although  distended,  were  not  indurated,  but  were  soft 
and  easily  compressible.  As  the  result  of  stripping, 
much  non-purulent  jellified  vesicular  material  was  ex- 
pressed. The  procedure  caused  the  patient  to  feel  very 
faint,  although  after  the  immediate  effects  of  the  manip- 
ulation had  passed  off  a  relief  from  the  symptoms  previ- 
ously complained  of  was  experienced.  After  subjecting 
himself  weekly  for  a  comparatively  short  period  to  the 
stripping  treatment  the  vesicles  regained  their  muscular 
tone,  and  all  the  symptoms  due  to  the  vesiculitis  disap- 
peared. This  case  represented  a  very  light  grade  of 
simple  inflammation,  and,  as  this  inflammation  was 
probably  of  comparatively  short  duration,  the  results 
obtained  from  the  treatment  were  speedy  and  most 
satisfactory. 

CASE  V.  Chronic  Seminal  Vesiculitis  Originating-  from  a 
Simple  Non-venereal,  Non-tubercular  Subacute  Inflamma- 
tion. The  chief  symptoms  •were  frequent  urination,  seminal 
emissions,  excessive  sexual  desire  associated  with  a  failure  of 
power,  nervous  reflex,  and  mental  disturbances.  A  young 
man,  aged  twenty-one  years,  of  good  physique ;  a  stu- 
dent; had  never  had  a  venereal  disease,  and  had  not 
abused  himself.  His  trouble  began  three  or  four  years 
previously  in  the  form  of  frequent  seminal  nocturnal 


186  MALE  SEXUAL  ORGANS. 

emissions,  together  with  an  occasional  stickiness  of  the 
meatus.  At  that  time  he  sought  medical  advice,  and 
was  treated  by  anterior  injections  and  by  the  passage  of 
sounds.  His  symptoms,  instead  of  getting  better,  grew 
rapidly  worse.  Further  medical  advice  was  sought  and 
deep  urethral  injections  prescribed,  and,  as  he  did  not 
improve,  perineal  section  was  suggested  to  him,  which 
suggestion  he  refused  to  entertain.  He  then  presented 
himself  for  the  first  time  to  the  writer.  He  had  been 
forced  by  his  troubles  to  give  up  his  college.  He  could 
not  read,  study,  or  make  any  prolonged  mental  effort 
without  becoming  confused.  He  had  many  nocturnal 
emissions,  sometimes  two  in  a  night.  Urination  was 
frequent,  and  there  was  a  burning  sensation  along 
the  urethra.  There  was  present  much  of  the  time  an 
excessive  sexual  craving.  "When,  however,  he  attempted 
to  gratify  it  his  erection  entirely  failed  him,  or  it  failed 
him  prematurely,  accompanied  by  a  premature  ejacula- 
tion. His  ejaculations  were  scanty  in  volume.  He  had 
a  muco-purulent  discharge  sufficient  to  soil  his  shirt. 
He  complained  that  his  penis  and  testicles  were  cold 
and  clammy  and  without  feeling.  He  slept  poorly  at 
night.  The  urine  was  clear,  aside  from  a  few  shreds 
and  a  little  extra  mucus.  Examination  of  the  vesicles 
per  rectum  showed  them  both,  and  especially  the  right 
one,  to  be  brawny,  tumefied,  and  distended,  much  ma- 
terial being  stripped  from  them.  The  patient  was 
ordered  to  take  active  exercise,  which  had  previously 
been  forbidden  him,  and  cod-liver  oil  was  prescribed, 
together  with  stripping  once  in  five  days.  At  the  end 
of  a  month  there  was  a  marked  improvement,  and  in 
six  months  the  patient  was  well  and  had  gained  thirty 
pounds  of  hard  flesh. 


ILLUSTRATIVE  INSTANCES.  187 

CASE  VI.  Chronic  Seminal  Vesiculitis  Originating-  from 
a  Simple  Non-venereal,  Non-tubercular  Subacute  Inflamma- 
tion. Urethral  tenderness  and  burning.  Sexual  disturb- 
ances. A  urethral  discharge.  Bacilliary  infection  of  the 
vesicles  associated  -with  a  constant  bacilliary  infection  of 
the  urine.  The  origin  and  early  stages  of  this  case  "were 
much  like  that  of  Case  V.  In  this  case,  however,  the  extra 
and  further  pathological  complication  of  vesicular  germ- 
infection  was  added.  A  young  man,  aged  twenty-nine 
years,  active,  of  good  habit  and  physique.  About  ten 
years  ago  he  had  begun  to  be  troubled  much  by  seminal 
emissions,  followed  some  time  afterward  by  urethral 
tenderness  and  burning ;  also  by  feelings  of  discomfort 
in  the  perineum.  These  feelings  in  the  perineum  were 
aggravated  by  pressure.  He,  therefore,  avoided  soft 
spring-seated  chairs,  preferring  those  with  hard  flat 
bottoms.  He  had  never  had  sexual  intercourse,  al- 
though he  had  been  much  annoyed  by  cravings  therefor 
and  by  painful  erections.  At  times,  also,  his  nocturnal 
emissions  were  very  painful,  and  they  were  often  fol- 
lowed by  marked  mental  depression.  For  the  last  three 
or  four  years  he  had  had  a  urethral  discharge,  which  he 
had  tried  unsuccessfully  to  cure  by  anterior  injections, 
and  which  he  had  been  told  was  gonorrhoea,  in  spite  of 
the  fact  that  he  had  never  exposed  himself.  He  had 
been  subjected  to  many  forms  of  treatment  without  any 
relief.  One  authority  had  assured  him  that  his  trouble 
lay  in  the  fact  that  he  had  a  long  foreskin.  He  had 
consequently  been  circumcised,  but  without  benefit. 
At  the  time  of  consulting  the  writer  feelings  of  impo- 
tency  and  loss  of  all  power  of  erection  had  taken  the 
place  of  the  opposite  conditions  which  had  formerly 
prevailed.  One  of  the  interesting  features  in  this  case, 
however,  was  the  fact  that  the  urine  was  loaded  with 


188  MALE  SEXUAL  ORGANS. 

bacteria.  There  were  no  evidences  of  kidney  or  pelvic 
disease.  The  seminal  vesicles  were  both  greatly  dis- 
tended and  their  walls  thickened.  There  was,  however, 
little  perivesicular  involvement.  A  large  quantity  of 
material  was  stripped  from  the  vesicles,  and  the  urine 
voided  directly  after  the  stripping  was  seen  to  contain 
a  greatly  increased  amount  of  bacteria.  These  germs 
were  examined  and  found  to  be  bacilli  coli  commune,  no 
tubercle  bacilli  or  other  varieties  of  germs  being  present, 
A  seminal  emission  streaked  with  blood  occurred  after 
the  stripping,  and  the  parts  were  left  very  sore.  After 
a  number  of  treatments  the  germs  in  the  urine  largely 
disappeared  and  his  symptoms  greatly  improved.  Before 
getting  entirely  well  he  married,  and  for  a  time  was 
troubled  by  sexual  weakness.  His  vesicles,  however, 
eventually  regained  their  tone  and  he  got  entirely  well. 
The  bacteria  entirely  disappeared  from  his  urine  before 
a  cure  of  his  vesiculitis  was  accomplished. 

CASE  "VII.  Chronic  Seminal  Vesiculitis.  Non-venereal, 
non-tubercular.  Originating  in  sexual  activity  at  an  early- 
age.  Painful  ejaculations  associated  at  times  with  blood. 
Severe  pain  in  lower  back  and  down  the  left  leg.  Burning 
and  painful  sensations  along  the  urethra.  Sexual  cravings. 
Little  satisfaction  or  relief  from  sexual  intercourse.  Melan- 
cholia. Could  not  apply  his  mind  to  business  without 
marked  mental  fatigue.  Suicidal  tendencies.  A  man, 
aged  thirty -five  years,  large  and  athletic.  At  the  age 
of  twelve  years  he  commenced  sexual  intercourse.  His 
family  lived  next  to  a  family  in  which  there  were  four 
girls,  most  of  whom  were  older  than  himself.  These 
girls  initiated  him  into  the  performance  of  the  sexual 
act,  and  for  a  considerable  period  gratified  themselves 
at  his  expense  on  all  available  occasions.  At  last  his 
family  becoming  alarmed  at  his  physical  condition  took 


ILLUSTRATIVE  INSTANCES.  189 

him  to  a  doctor,  who  told  them  that  he  must  be  a 
masturbator.  He  continued  to  practise  sexual  inter- 
course all  through  his  early  youth,  although  to  a  much 
less  extent  than  at  first.  Eventually  he  married,  but, 
from  a  fear  of  having  children,  his  sexual  acts  were  un- 
natural. He  habitually  interrupted  the  completion  of 
the  act  by  resorting  to  a  premature  withdrawal.  He 
began  at  this  time  to  complain  of  a  pain  in  the  lower 
back  and  of  a  sexual  craving  associated  with  little 
sexual  satisfaction  from  coitus,  together  with  sexual 
weakness  and  premature  ejaculations.  His  wife  then 
died  and  he  resorted  to  sexual  excesses.  The  symptoms 
just  enumerated,  however,  grew  worse,  and  on  one 
occasion,  while  in  the  performance  of  the  sexual  act,  he 
experienced  a  severe  stabbing  pain  in  the  deep  perineum, 
associated  apparently  with  the  ejaculatory  act.  The 
pain  was  so  severe  that  he  felt  very  faint,  and  became 
bathed  in  a  cold  perspiration.  Blood  also  trickled  from 
the  meatus.  The  pain  in  his  back,  combined  with  a 
shooting  pain  down  the  left  thigh  in  the  region  of  the 
sciatic  nerve,  was  so  severe  immediately  after  this  attack 
that  a  large  hypodermic  injection  of  morphine  was  re- 
quired to  render  it  bearable.  After  this  accident  his 
symptoms  became  apparently  much  worse.  He  became 
melancholy  and  unable  to  apply  himself  to  his  business. 
If  he  exerted  himself  at  his  business  for  one  day,  he 
would  be  mentally  prostrated  for  the  next  day  or  so. 
After  this,  as  he  had  involuntary  emissions  associated 
with  more  or  less  bleeding,  the  doctor  whom  he  con- 
sulted tried  deep  urethral  applications,  but  with  no 
success.  The  case  then  came  under  the  observation  of 
the  writer.  Both  vesicles,  but  especially  the  right,  were 
found  to  be  very  tender,  indurated,  and  distended.  The 
induration  also  did  not  confine  itself  to  the  vesicular 


190  MALE  SEXUAL  ORGANS. 

walls,  but  involved  extensively  the  perivesicular  tissues. 
As  the  result  of  the  stripping  a  large  amount  of  in- 
flamed vesicular  material,  somewhat  discolored  by  blood, 
dripped  from  the  meatus.  The  manipulation  tempo- 
rarily intensified  to  a  marked  degree  the  pain  in  the 
lower  back  and  in  the  left  thigh.  This  case,  owing  to 
its  chronic  history  and  to  its  extensive  pathological 
indications,  led  the  writer  at  the  time  to  suspect  that 
it  would  prove  stubborn  as  regards  the  treatment  rec- 
ommended for  this  disease.  After  three  months'  treat- 
ment, however,  the  distressing  symptoms  had  so  far 
disappeared  that  the  man  was  comfortable;  and  now,  at 
the  end  of  eight  months,  he  feels  himself  to  be  perfectly 
well.  The  vesicles,  however,  although  showing  marked 
improvement,  are  not  as  yet  satisfactory  to  the  feel,  and 
will  probably  require  from  four  to  six  months'  further 
treatment. 

CASE  "VIII.  Chronic  Seminal  Vesiculitis,  Non-venereal, 
Non-tubercular.  The  feature  in  this  case  was  an  irresistible 
desire  to  masturbate.  Involuntary  masturbation  at  times 
during-  sleep.  Sexual  craving's.  Sexual  powers  uncertain. 
Nervous  symptoms.  A  man,  aged  thirty  years,  physi- 
cally robust.  Leads  a  sedentary  life.  At  the  age  of 
ten  years  he  began  to  masturbate,  and  continued  the 
practice  more  or  less  ever  since.  He  indulged  himself 
sexually  at  times,  and  at  those  times  he  had  little  desire 
to  masturbate.  During  the  last  two  years  the  desire  to 
masturbate  has  increased  very  markedly,  and  now  when 
the  desire  seizes  him  he  cannot  resist  it.  One  single  act 
also  does  not  suffice  to  dispel  the  craving,  but  it  is  re- 
peated over  and  over  again  continuously,  or  many  times 
a  day  for  a  period  of  several  days.  An  uncertain  period 
of  respite  then  occurs,  during  which  the  act  is  not  prac- 


ILLUSTRATIVE  INSTANCES.  191 

tised.  During  these  periods  of  masturbation  little  or  no 
relief  from  the  craving  follows  each  separate  act,  but 
each  act  seems  rather  to  increase  the  craving,  till  a  sense 
of  physical  exhaustion  occurs  which  breaks  the  attack. 
Latterly,  the  act  of  masturbation  has  at  times  become 
wholly  involuntary,  as  on  numerous  occasions  he  has 
awakened  from  sleep  finding  himself  practising  it. 
Formerly,  by  resorting  to  sexual  intercourse,  he  could 
dispel  the  desire  for  it ;  but  latterly  his  sexual  powers 
have  become  so  weak  that  he  can  only  occasionally 
accomplish  coitus,  and  when  he  does,  he  experiences  no 
satisfaction  or  relief  therefrom.  His  erections  also, 
which  formerly  were  strong,  are  now  weak  and  of  rare 
occurrence,  the  act  of  masturbation  even  being  gen- 
erally accomplished  without  exciting  or  occasioning  that 
condition.  Generally  after  these  periods  of  excessive 
masturbation  he  has  been  troubled  with  a  muco-puru- 
lent  urethral  discharge,  which  he  has  subdued  by 
anterior  astringent  injections.  Latterly  his  hand  has 
become  very  tremulous,  as  well  as  his  lips.  His  mental 
faculties  are,  however,  good  and  steady.  Indeed,  this 
fact  struck  the  writer  as  remarkable  on  first  examining 
the  case,  and  this,  together  with  his  frank  confession  of 
his  troubles,  led  the  author  to  believe  that  the  cause  of 
the  troubles  complained  of  was  not  psychological,  but 
local  in  the  sexual  apparatus.  The  vesicles  were,  there- 
fore, examined  and  found  to  be  chronically  inflamed  and 
distended,  with  thickened  walls.  A  series  of  strippings 
were  commenced,  and  hygienic  methods  of  living,  in- 
cluding much  physical  exercise,  were  also  prescribed. 
After  two  months'  treatment  he  experienced  great  relief 
— the  desire  to  masturbate  left  him,  his  sexual  feelings, 
together  with  his  erections,  became  normal,  and  his 
tremulousness  disappeared.    Treatment  was  followed  up 


192  MALE  SEXUAL  ORGANS. 

for  several  months  after  the  relief  from  the  symptoms 
had  been  experienced,  and  until  the  conditions  of  the 
vesicles  seemed  satisfactory.  The  patient  was  then 
discharged  and  advised  to  marry. 

CASE  IX.  Chronic  Seminal  Vesiculitis  of  Gonorrhceal 
Origin.  Marked  vesical  tenesmus.  Micturition  frequent  and 
at  times  involuntary.  Priapism.  Frequent  sensations  of 
emission,  which  were  involuntary.  Almost  no  fluid  ejacu- 
lated at  the  time  of  an  emission.  Intermittent  urethral 
discharge.  A  man,  aged  thirty-three  years,  general 
health  good.  He  had  gonorrhoea  seven  years  ago. 
Apparently  recovered  from  it,  but  ever  since  the  attack 
at  times  the  urinary  act  has  been  frequent  and  rather 
precipitate.  Three  years  ago  he  married,  but  has  never 
had  children.  Some  months  ago,  after  drinking,  a 
urethral  discharge  appeared,  which  he  had  found  impos- 
sible to  cure,  although  occasionally  it  would  apparently 
disappear,  and  since  that  time  he  has  felt  disposed  to 
overdo  himself  sexually.  About  a  month  before  con- 
sulting the  writer,  after  the  passage  through  the  deep 
urethra  of  a  large-sized  sound,  the  following  distressing 
symptoms  appeared,  which  led  him  to  seek  the  author's 
advice :  His  desire  to  urinate  was  very  frequent  day 
and  night,  and  at  times  it  was  almost  incessant,  asso- 
ciated with  a  violent  vesical  tenesmus.  So  involuntary 
and  frequent  was  his  urination  that  a  rubber  urinal  had 
to  be  worn.  Persistent  priapism  was  also  a  feature. 
This  symptom  was  so  marked  as  to  be  painful,  and  the 
more  the  vesical  tenesmus  the  more  the  priapism.  As- 
sociated with  the  priapism,  and  especially  noticeable  at 
the  time  of  vesical  tenesmus,  were  feelings  which  seemed 
to  indicate  that  attempts  at  ejaculation  were  being  made. 
]STo  semen,  however,  appeared  at  the  meatus.     In  order 


ILLUSTRATIVE  INSTANCES.  193 

to  rid  himself  of  the  priapism  and  of  the  sensations  of 
ejaculation  he  had  recourse  to  frequent  and  prolonged 
attempts  at  coitus,  without  experiencing,  however,  any 
relief.  His  urine  was  purulent,  as  was  to  be  expected, 
owing  to  the  violent  tenesmus.  He  was  examined  for 
calculus,  but  none  was  found.  Both  seminal  vesicles 
were  found  to  be  brawny  and  very  much  distended,  a 
large  quantity  of  purulent  fluid  being  stripped  out, 
among  which  were  several  clumps  of  inspissated  ma- 
terial, which  appeared  sufficient  to  plug  the  ejaculatory 
ducts.  Although  the  stripping  process  caused  much 
pain  and  made  him  feel  faint  at  the  time,  yet  he  soon 
experienced  some  relief  from  his  annoying  symptoms. 
After  a  few  weeks  he  left  the  city  feeling  comparatively 
comfortable;  and  after  his  return  to  his  home,  as  the 
result  of  further  similar  treatment  at  the  hands  of  his 
local  adviser,  he  still  further  improved. 

In  this  case  the  vesiculitis  had  evidently  existed  for 
a  number  of  years,  without,  however,  giving  rise  to  any 
marked  symptoms  until  it  was  stirred  into  activity  by 
the  passage  of  the  large-sized  sound. 

CASE  X.  Chronic  Seminal  Vesiculitis  of  probable  Gon- 
orrhceal  Origin.  Marked  sexual  weakness.  Periods  of  im- 
potency.  Difficulty  in  voiding-  urine.  Frequent  attacks  of 
temporary  retention.  A  man,  aged  forty-three  years. 
In  early  adult  life  he  had  gonorrhoea  several  times,  and 
also  indulged  himself  sexually  to  excess.  A  number  of 
years  ago  he  married,  and  since  then  he  has  lived  cor- 
rectly. For  several  years  he  has  noticed  that  his  sexual 
powers  have  been  waning,  and  when  first  seen  his  erec- 
tions were  entirely  wanting,  or,  at  best,  feeble,  so  that 
he  was  able  to  accomplish  coitus  only  very  rarely,  and 
then  imperfectly.     Corresponding  apparently  in   great 

13 


194  MALE  SEXUAL  ORGANS. 

measure  with  his  advancing  sexual  weakness,  a  diffi- 
culty in  voiding  his  urine  manifested  itself.  This  diffi- 
culty at  the  time  of  his  first  consultation  with  the  author 
was  so  marked  that  attacks  of  complete  retention  last- 
ing several  hours  were  frequent,  resort  to  a  hot  sitz-bath 
being,  as  a  rule,  necessary  in  order  to  start  the  stream. 
These  attacks  of  retention  generally  occurred  in  the 
morning  on  getting  out  of  bed,  and  at  any  time  when 
he  was  at  all  mentally  agitated.  The  expulsive  force  of 
his  bladder  at  best  seemed  weak,  and  the  latter  portion 
of  the  urinary  act  always  terminated  in  a  dribble.  He 
had  been  told  that  he  had  stricture,  and  had  been 
treated  therefor.  Such  treatment,  however,  instead  of 
benefiting  him  had  proved  detrimental.  Examination 
also  of  the  urethra  with  a  full-sized  blunt  sound  showed 
that  no  stricture  existed.  The  deep  urethra,  however, 
was  found  to  be  very  sensitive  and  spasmodic.  The 
urine  was  clear,  with  the  exception  of  a  few  shreds,  and 
contained  nothing  abnormal,  aside  from  the  shreds. 
There  were  in  the  shreds,  however,  seminal  elements. 
The  cystoscope  showed  the  bladder  to  be  normal,  and 
no  disease  of  the  spinal  cord  could  be  detected.  The 
seminal  vesicles,  however,  were  found  to  be  very  much 
distended  and  thickened  and  surrounded  by  an  exten- 
sive peri  vesicular  induration.  This  peri  vesiculitis  had 
all  the  evidences  of  chronicity.  It  was  firm,  fibrous,  non- 
cedematous,  and  but  slightly  sensitive.  Stripping  the 
vesicles  dislodged  a  great  quantity  of  thickened  gelatin- 
ous vesicular  material.  The  stripping  treatment,  asso- 
ciated with  vesical  lavage  (gr.  J  of  bichloride  of  mercury 
in  8  ounces  of  hot  water),  was  instigated.  This  was 
followed  by  slow  but  progressive  improvement.  At  the 
end  of  six  months  his  stream  came  freely,  with  good 
force,  and  he  rarely  had  times  when  it  was  at  all  difficult 


ILLUSTRATIVE  INSTANCES.  195 

to  start  the  urine.  His  sexual  power  also  showed  much 
improvement.  His  erections  and  sensations  were  better 
and  more  natural.  He  could  accomplish  coitus  satis- 
factorily once  or  twice  a  week.  At  this  time  also  the 
vesicles  had  improved  much  to  the  feel.  The  peri- 
vesicular  induration  had  diminished  and  become  softer, 
and  the  vesicular  walls  less  distended  and  more  elastic. 
At  this  stage  of  the  treatment  the  patient  disappeared 
from  view,  expressing  himself  as  satisfied  with  his  con- 
dition. It  is  probable,  however,  that  the  case  had  not 
been  treated  sufficiently,  and  that  gradually  the  parts  if 
left  to  themselves  would  tend  to  relapse  to  their  former 
condition.  With  a  more  extended  treatment,  however, 
the  vesicular  improvement  would  doubtless  have  pro- 
gressed further  and  a  stage  been  reached  where  the 
advantages  obtained  would  have  tended  to  remain  per- 
manent. In  a  case  similar  to  this  one,  owing  to  its 
great  chronicity  and  to  the  age  of  the  patient,  improve- 
ment would  naturally  be  slower  than  in  one  of  a  tenderer 
age  and  in  whom  the  commencement  of  the  pathological 
process  was  more  recent. 

CASE  XI.  Chronic  Seminal  Vesiculitis,  of  probable  Gon- 
orrhceal  Origin,  occurring'  in  an  Elderly  Individual,  asso- 
ciated with  Chronic  Prostatic  Hypertrophy.  Active  vesic- 
ular symptoms  first  noted  seven  years  previously,  following 
a  vigorous  treatment  for  alleged  stricture  by  means  of  elec- 
trolysis. Loss  of  sexual  power.  A  chronic  urethral  dis- 
charge. Little  or  no  benefit  from  treatment.  A  man,  aged 
fifty-seven  years.  During  youth  and  middle  life  he  had 
indulged  himself  sexually  very  freely.  He  had  had 
gonorrhoea  several  times,  and  had,  so  he  thought,  always 
gotten  over  it  with  little  trouble.  When  about  forty- 
five  years  he  noticed  that  after  any  sexual  excess  a 
urethral  moisture  would  appear,  and  would  persist  for 


196  MALE  SEXUAL  ORGANS. 

several  days.  This  symptom  became  more  and  more 
troublesome,  and  the  moisture  increased  at  such  times 
into  a  muco-purulent  discharge.  He  also  noticed  that 
his  sexual  powers  were  not  what  they  ought  to  be. 
When  about  fifty  he  sought  surgical  advice  for  these 
symptoms,  and  was  told  that  his  trouble  was  due 
to  urethral  stricture,  and  a  cure  by  electrolysis  was 
attempted.  The  current  was  so  strong,  however,  as  to 
cause  free  hemorrhage  from  the  deep  urethra — the  part 
where  it  was  applied — together  with  great  vesical  te- 
nesmus. After  this  trial  of  electricity — and  he  never 
allowed  another  to  be  made — frequency  of  urination 
persisted  for  a  long  time,  together  with  painful  erec- 
tions. For  a  while  after  this  he  had  sexual  cravings 
and  some  priapism.  These  latter  symptoms  were,  how- 
ever, eventually  replaced  by  loss  of  erectile  power  and 
of,  in  large  measure,  sexual  sensations.  The  urinary 
symptoms  also  became  less  troublesome,  but  a  chronic 
discharge  persisted,  and  free  pus  could  always  be  found 
in  the  urine.  At  this  stage  he  came  under  the  author's 
observation.  He  had  a  certain  amount  of  urethral 
stricture,  marked  senile  prostatic  hypertrophy,  and  a 
very  chronic  and  extensive  seminal  vesiculitis,  compli- 
cated with  extensive  perivesiculitis,  in  connection  with 
both  sacs.  The  stripping  treatment  was  tried  for  a 
time  without  apparently  making  any  special  impression 
on  the  vesicular  condition  or  improving  the  symptoms 
complained  of,  and  it  is  probable  that  at  the  time  of  life 
of  the  patient,  especially  when  there  also  exists  senile 
prostatic  hypertrophy,  this  treatment  is  of  little,  if  any, 
value.  A  perineal  operation,  with  division  of  the 
strictures  and  the  removal  if  necessary  of  a  portion  of 
the  prostate,  might  have  served  to  remove  or  lessen  the 
vesical  free  pus  and  the  chronic  urethral  discharge  ;  but, 


ILLUSTRATIVE  INSTANCES.  197 

as  the  catarrhal  vesicles  would  still  be  left,  the  condition 
of  the  patient  would  probably  remain  unsatisfactory. 
Extirpation  of  the  vesicles  would  remove  the  chief  focus 
of  pus,  but  in  the  patient's  comparatively  comfortable 
state  such  a  radical  measure  would  hardly  be  called  for. 

CASE  XII.  Chronic  Seminal  Vesiculitis  of  G-onorrhceal 
Origin.  Frequent  and  painful  urinations.  Severe  pain  on 
ejaculation.  Chronic  urethral  discharge  associated  fre- 
quently "with  blood.  A  few  drops  of  blood  generally  fol- 
lowed each  act  of  urination.  This  case  was  taken  from  the 
list  published  by  the  author  in  his  article  on  "Persistent 
Urethral  Discharges,"  etc.  {Journal  of  Cutaneous  and  G-enito- 
Urinary  Diseases,  June  and  July,  1894).  "  A  man,  aged 
twenty-seven  years,  came  complaining  of  a  urethral 
discharge  associated  with  frequent  and  painful  urina- 
tion. At  the  end  of  each  urinary  act  it  was  customary 
for  a  drop  or  two  of  blood  to  appear  at  the  meatus.  He 
also  suffered  much  pain  on  the  occurrence  of  a  seminal 
emission.  These  disagreeable  symptoms  had  persisted 
for  two  years  as  the  result  of  a  gonorrhoea.  In  the  mean- 
time the  patient  had  been  treated  at  the  hands  of  numer- 
rous  eminent  medical  men  without  relief.  His  meatus 
had  been  cut,  large  sounds  passed,  deep  and  anterior  in- 
jections used,  and  topical  applications  through  the  endo- 
scope applied,  all  with  the  result  of  aggravating  rather 
than  improving  the  existing  state  of  affairs.  Endo- 
scopic examination  did  show  a  beefy-looking,  granular 
spot  in  the  deep  urethra.  Rectal  feel  showed  both 
vesicles  to  be  tender,  distended,  and  inflamed.  Much 
material,  associated  with  pus  and  blood,  was  squeezed 
from  them.  It  was  thought  best  to  leave  the  granular 
spot  in  the  deep  urethra  alone,  and  to  treat  simply  the 
vesicles  by  the  usual  method,  once  in  every  five  to 
seven  days.     During  the  first  six  weeks  of  treatment, 


198  MALE  SEXUAL  ORGANS. 

though  the  vesicular  feel  was  constantly  improving,  the 
patient,  made  skeptical  perhaps  by  his  former  experi- 
ences, did  not  admit  that  he  was  any  better,  aside  from 
the  fact  that  painful  sensations  at  the  time  of  seminal 
emissions  had  disappeared.  Shortly  after  this  time  the 
discharge,  the  blood,  and  the  frequent  painful  urinations 
all  disappeared.  Then  the  patient  became  enthusiastic 
and  wanted  to  call  himself  cured.  Treatment  was  con- 
tinued, however,  for  some  time,  until  the  condition  of 
the  vesicles  became  quite  satisfactory  to  the  feel.  Since 
the  discharge  stopped,  now  six  months  ago,  the  patient 
has  considered  himself  perfectly  well,  and  he  has  been 
well  as  far  as  his  urinary  apparatus  is  concerned.  It 
has  been  difficult  in  this  case  to  impress  on  the  patient 
the  importance  of  having  the  vesiculitis  entirely  cured 
before  abandoning  treatment.  On  this  account  there 
may  be  some  future  trouble  in  store  for  him." 

This  case  has  remained  perfectly  well.  He  was  ex- 
amined by  the  author  about  six  months  after  the  pre- 
ceding account  was  written,  and  was  then  found  to  be 
perfectly  well.     Since  then  he  has  married. 

CASE  XIII.  Chronic  Seminal  Vesiculitis  due  to  Gonor- 
rhoea. In  the  early  history  blood  was  associated  much  as 
in  Case  XII.,  with  a  persistent  urethral  discharge.  Urgent 
and  frequent  urinations.  Pain  in  the  perineum.  Sexual 
disturbances.  This  case  also,  like  the  preceding  one,  was 
taken  from  the  author's  list  in  the  article  referred  to.  "  A 
man,  aged  thirty-five  years,  had  a  gonorrhoea  in  1889, 
and  had  not  been  well  since.  This  statement  was  made 
early  in  September,  1893.  Daring  1890  and  1891  he 
suffered  much  from  a  relapsing  discharge  associated 
sometimes  with  blood.  At  this  period  also  his  urina- 
tions were  frequent  and  urgent.     In  the  urine,  besides 


ILLUSTRATIVE  INSTANCES.  199 

free  pus,  there  were  large  clumpy  shreds  from  the  deep 
urethra,  with  oftentimes  some  adhering  blood-clots. 
Numerous  urethral  treatments  were  tried  without  bene- 
fit, and  in  1892  he  submitted  to  perineal  section  and 
drainage.  From  this  operation  he  received  considerable 
benefit.  The  bloody  element  disappeared  and  only  a 
slight  gieety  discharge  remained.  His  urinations  were, 
however,  still  quite  frequent  and  urgent.  He  had  pain 
in  the  perineum,  and  he  experienced  little  satisfaction  or 
relief  from  sexual  intercourse.  In  September,  1893,  the 
seminal  vesicles  having  been  found  to  be  distended  and 
inflamed,  stripping  was  tried,  and  much  firm  gelatinous 
material  pressed  out.  This  course  was  continued  at 
frequent  intervals  for  two  months,  and  then  more  infre- 
quently for  three  months  longer.  Under  this  treatment 
the  discharge  soon  wholly  disappeared,  together  with 
the  perineal  pain,  the  urinations  became  normal  as  re- 
gards frequency  and  urgency,  and  his  sexual  sensations 
were  again  natural.  In  all  probability  in  this  instance 
much  discomfort,  together  with  the  perineal  section, 
might  have  been  avoided  had  the  value  of  vesicular 
strippings  been  known  two  years  or  more  before.  Still 
there  is  much  satisfaction  in  making  a  final  cure  in  such 
a  case." 

It  seems  probable  that  the  rest  in  this  case  rather 
than  the  cutting  was  what  caused  the  improvement 
which  followed  after  the  perineal  incision.  In  fact,  the 
first  two  years  of  suffering  in  this  case  were  an  almost 
exact  counterpart  of  that  in  Case  XII.  In  this  case 
also  the  sexual  sensations,  which  were  intensified  during 
the  early  stages  of  the  disease,  had  become  inactive 
before  the  stripping  treatment,  and  his  erections  had 
become  weak  and  uncertain. 


200  MALE  SEXUAL  ORGANS. 

CASE  XIV.  Chronic  Seminal  Vesiculitis  of  probable 
Gonorrheal  Origin.  Painful  and  bloody  emissions.  Hem- 
orrhage into  the  cavity  of  the  vesicle  resulting-  from  hard 
stripping-.  Marked  sexual  weakness.  Sexual  desire  at 
times  very  strong.  Urethral  and  reflex  neurotic  symptoms. 
Marked  mental  disturbances.  A  man,  aged  forty-two 
years,  of  good  physique.  In  earlier  life  he  had  had 
several  attacks  of  gonorrhoea.  Some  of  them  had  ap- 
parently been  slow  in  getting  well,  but  otherwise  had 
given  him  little  trouble.  Some  years  ago  he  had  been 
troubled  with  gleet,  but  had  been  cured  by  the  passage 
of  sounds.  Formerly  he  had  overindulged  sexually, 
and  had  considered  himself  more  potent  than  most  men. 
Of  late  years,  however,  although  at  times  amorously 
inclined,  he  had  found  himself  always  sexually  weak, 
and  often  the  thought  of  women  would  be  distasteful 
to  him.  Latterly  also,  in  order  to  insure  a  successful 
accomplishment  of  the  sexual  act,  he  had  felt  it  neces- 
sary to  drink  freely  of  beer.  Formerly  he  complained 
of  frequent  and  debilitating  nocturnal  emissions.  Then 
they  became  more  infrequent,  but  when  they  did  occur 
they  were  generally  painful.  The  act  of  ejaculation 
also  during  coitus  was  often  acutely  painful,  and  on 
occasions  he  noticed  that  his  seminal  discharges  were 
bloody.  After  coitus,  and  also  after  involuntary  emis- 
sions or  sexual  excitement,  he  experienced  a  dull  pain 
in  the  back  and  across  the  kidney  region.  A  severe 
headache  also  usually  accompanied  the  pain  in  the  back. 
After  straining  at  stool,  thick,  pasty,  viscid  material 
generally  appeared  at  the  meatus.  For  some  time  he 
had  experienced  great  difficulty  in  sleeping,  and  some 
nights  he  could  not  sleep  at  all.  To  remedy  this  he 
had  taken  numerous  drugs,  with,  however,  no  real  relief. 
Oftentimes,  in  order  to  obtain  rest,  he  had  taken  whiskey 


ILLUSTRATIVE  INSTANCES.  201 

in  sufficient  quantities  to  produce  intoxication.  He  had 
become  generally  very  irritable  and  quarrelsome,  so 
much  so,  in  fact,  that  he  found  it  difficult  to  do  busi- 
ness. On  several  occasions  he  had  wholly  lost  control 
of  himself  and  had  assaulted  individuals  for  really 
trivial  offences.  He  began  to  have  delusions,  and  to 
think  that  people  generally  were  plotting  against  him. 
He  said  that  his  friends  thought  he  was  going  crazy, 
and  at  times  he  felt  that  he  was  not  responsible  for  his 
actions.  He  sought  advice  at  the  hands  of  several 
specialists  on  nervous  and  mental  diseases  without 
benefit.  He  had  been  told  that  his  trouble  was  due  to 
urethral  stricture,  since  at  times  he  had  a  burning  sen- 
sation along  the  urethra,  associated  with  some  vesical 
irritation  and  frequency  of  urination,  and  it  was  to  be 
cured  of  stricture  of  the  urethra  that  he  first  sought 
the  author's  advice.  Examination  did  show  that  he  had 
anterior  urethral  stricture  to  a  moderate  extent.  He 
had,  however,  recently  been  treated  for  stricture  by  the 
use  of  sounds,  and  thought  he  had  been  made  worse 
by  the  treatment.  His  vesicles  were  examined  and 
found  to  be  extensively  involved  by  a  chronic  inflam- 
mation. Their  walls  were  very  thick  and  hard  and 
knobby  to  the  feel.  They  were  both  distended,  but  the 
right  one  more  so  than  the  left.  There  was  also  a  peri- 
vesicular  induration,  which  was  extensive  enough  to  fill 
up  the  space  between  the  two  organs.  On  stripping 
the  sacs  a  large  amount  of  inflammatory  vesicular  ma- 
terial was  expressed,  somewhat  tinged  with  blood.  The 
regular  treatment  by  stripping  the  sacs  was  commenced, 
although  a  guarded  prognosis  was  given  owing  to  the 
severity  of  the  symptoms,  the  age  of  the  patient,  and 
the  extent  and  duration  of  the  pathological  process. 
This  treatment  was  continued  for  about  six  weeks,  and 


202  MALE  SEXUAL  ORGANS. 

had  been  attended  with  a  moderate  relief  of  the  symp- 
toms complained  of,  when,  as  the  result  of  a  stripping 
probably  somewhat  too  severe,  a  copious  hemorrhage 
into  the  right  vesicle  took  place.  The  sudden  disten- 
tion of  the  sac  caused  the  patient  to  be  seized  with  a 
painful  and  violent  desire  for  sexual  intercourse,  which 
desire  he  promptly  endeavored  to  gratify.  The  result 
was  a  copious  bloody  ejaculation  accompanied  with 
much  pain.  Blood  also  continued  to  drip  from  the 
meatus  for  some  time  after  the  completion  of  the  act. 
This  hemorrhage  increased  the  vesicular  symptoms  for 
the  time  being,  also  frightened  the  patient.  He,  there- 
fore, sought  advice  elsewhere.  He  went  to  a  specialist 
on  mental  diseases,  and,  as  this  gentleman  could  not 
aid  him,  he  sent  him  to  a  surgeon,  who  endeavored  to 
cure  the  anterior  strictures  by  vigorous  dilatation.  The 
result  of  this  last  treatment  was  that  the  patient  was 
made  worse.  He  then  came  back  to  the  author  and 
stated  that  the  treatment  of  stripping  the  sacs  was  the 
only  method  which  had  ever  done  him  any  good,  and 
that  he  wished  it  continued;  also  that  he  would  not 
again  desert  the  author,  no  matter  what  happened. 
The  stripping  treatment  was  accordingly  resumed,  and 
now,  after  about  eight  months,  the  patient  is  comfort- 
able. He  can  sleep  and  attend  to  business.  He  is  not 
irritable  and  can  control  himself.  His  sexual  power  is 
still  very  weak,  but,  as  he  has  no  uncomfortable  feelings 
of  desire,  he  expresses  himself  as  satisfied.  He  rarely 
also  feels  the  reflex  pains  in  the  back.  The  induration 
in  connection  with  the  vesicular  walls  and  with  the  peri- 
vesicular  tissues  has  been  somewhat  absorbed.  Still 
much  remains.  All  that  can  be  done  for  an  extreme 
case  like  this  one  is  to  make  life  comfortable,  a  positive 
cure   being   out   of  the   question.     How  much   future 


ILLUSTRATIVE  INSTANCES.  203 

treatment  this  case  may  require  it  is  impossible  to  state, 
but  probably  a  little  from  time  to  time  will  be  enough 
to  keep  him  comfortable. 

CASE  X"V\  Chronic  Seminal  Vesiculitis.  Calculus  of  the 
Seminal  Vesicle.  Gonorrhoea  two  years  before  the  time  of 
seeking  advice.  Pain  in  the  lower  back.  Pain  in  the  tes- 
ticle. Shooting  pains  at  times  extending  along  the  penis. 
Bloody  emissions.  A  man,  aged  twenty-nine  years, 
strong  and  generally  healthy.  Had  gonorrhoea  two 
years  ago  complicated  with  a  double  epididymitis.  For 
many  years  has  had  to  get  up  once  at  night  to  void  his 
urine.  For  a  considerable  interval,  in  fact,  as  he  recalls 
it,  almost  since  the  time  of  his  gonorrhoea,  he  has  been 
troubled  with  a  persistent  pain,  generally  dull,  but 
sometimes  sharp,  in  the  right  sacral  region.  While 
busy  and  active  he  is  not  apt  to  notice  this  pain,  but 
when  he  lies  down  or  sits  it  always  asserts  itself,  and 
latterly  it  has  become  more  severe  and  troublesome. 
After  working  hard  he  generally  experiences  a  pain  in 
the  right  testicle.  Sometimes  he  has  a  pain  also  above 
the  pubes,  which  is  liable  to  radiate  downward  along 
the  penis  as  a  burning  sensation.  His  urine  contains  a 
slight  amount  of  pus  and  more  mucus  than  is  normal. 
He  leads  an  active  outdoor  life.  He  thinks  little  about 
his  sexual  function,  and  has  no  complaint  to  make  re- 
garding it.  He  has  nocturnal  emissions  from  time  to 
time,  and  lately  he  has  noticed  that  they  were  bloody. 
The  act  itself  is  not  painful,  but  he  thinks  that  the  pain 
in  the  back  is  worse  after  an  emission.  It  was  owing 
to  the  bloody  character  of  the  emissions  that  the  author's 
advice  was  sought.  Rectal  digital  examination  showed 
the  right  seminal  vesicle  to  be  boggy  and  inflamed, 
presenting  to  the  feel  a  tumor  the  size  of  a  hen's  egg. 


204  MALE  SEXUAL  ORGANS. 

This  tumor  was  made  up  of  the  distended  vesicle  with 
thickened  walls,  together  with  an  cedematous  circum- 
scribed peri  vesiculitis.  The  left  vesicle  was  normal. 
On  stripping  the  right  vesicle  a  large  amount  of  thick 
purulent  vesicular  fluid  dripped  from  the  meatus.  This 
pathological  fluid  was  brown,  due  to  the  admixture  of 
blood.  The  admixture,  judging  from  its  color  and 
general  appearance,  was  of  some  duration,  and  not 
caused  by  the  stripping.  In  five  days'  time  the  patient 
reported  again.  He  stated  that  the  stripping  had  ap- 
parently caused  him  more  pain  in  the  sacral  region. 
Examination  at  this  time  showed  the  vesicle  even  more 
tumefied  than  when  first  seen.  On  stripping  it  also  a 
large  amount  of  material  was  forced  out.  This  time 
there  was  much  blood,  mostly  bright  red,  showing  that 
the  bleeding,  if  not  caused  by  the  second  stripping,  was 
at  least  very  recent.  The  manipulation  also  caused  a 
severe  pain  in  the  back.  On  the  night  following  this 
second  treatment  he  had  a  copious  emission  associated 
with  a  stabbing  pain.  Examination  showed  this  to 
consist  of  a  large  blood-clot,  and  in  the  clot  a  rough 
calculus  resembling  a  grape-seed  in  size  and  shape  was 
found.  After  the  passage  of  this  concretion  the  patient 
felt  better  and  the  pain  in  the  back  was  less.  A  week 
after  this  occurrence  he  reported  again  for  treatment. 
The  vesicle  then  was  about  half  its  former  size  and  not 
so  tender.  Stripping  it  forced  out  a  moderate  amount 
of  purulent  vesicular  material,  which,  however,  was  free 
from  blood-stain.  After  this  the  patient  speedily  con- 
valesced, the  vesicle  being  stripped  at  weekly  intervals. 
This  case  was  a  most  interesting  one  to  the  author. 
The  first  two  strippings  evidently  dislodged  the  concre- 
tion and  forced  it  down  into  and  partially  along  the 
ejaculatory  duct.     Then  the  free  hemorrhage  into  the 


ILLUSTRATIVE  INSTANCES.  205 

sac  due  to  the  laceration  from  the  calculus,  by  overdis- 
tending  the  sac,  caused  a  vigorous  contraction,  the 
result  being  that  the  concretion  was  flushed  out  with 
the  blood-clot. 


CASE  X~VT.  Chronic  Seminal  Vesiculitis.  Gonorrhoea 
and  sexual  excesses  in  youth.  Pain  at  the  neck  of  the 
bladder.  Perineal  pain  and  tenderness.  Had  to  sit  on  a 
rubber  ring  to  avoid  pressure  on  the  perineum.  Attacks  of 
pain  radiating  from  the  vesical  neck  upward  toward  the 
right  kidney.  Sexual  power  weak  and  uncertain.  Pain  on 
ejaculation,  followed  by  a  soreness  which  persisted  for 
several  days.  Scanty  amount  of  fluid  thrown  out  by  the 
ejaculatory  act.  So-called  nervous  prostration.  Numerous 
reflex  symptoms.  A  man,  aged  forty-eight  years,  not  very 
robust.  During  his  youth  he  had  indulged  himself 
sexually  quite  freely.  Had  had  gonorrhoea.  For  a 
number  of  years  his  sexual  power  had  been  very  weak 
and  uncertain.  His  sexual  desire  also  had  been  largely 
dormant.  For  a  long  time  he  had  had  an  aching  pain 
at  the  neck  of  the  bladder,  associated  with  a  pain  and 
tenderness  in  the  perineum.  Pressure  on  the  perineum 
increased  the  pain  there,  as  well  as  at  the  neck  of  the 
bladder.  So  sensitive  had  he  become  to  pressure  in  that 
part  that  he  habitually  carried  about  an  inflated  rubber 
ring,  which  he  slipped  beneath  him  whenever  he  sat,  so 
as  to  remove  all  pressure  from  the  tender  area.  His 
urinary  acts  were  natural,  with  the  exception  that  at 
night  he  had  to  get  up  once.  His  urine  also  was  clear 
and  normal.  Sometimes  the  pain  at  the  bladder  neck 
would  radiate  upward,  generally  toward  the  right  kidney, 
or  down  into  the  testicles.  Whenever  he  attempted 
sexual  intercourse  and  was  able  to  accomplish  the  act, 
which  was  seldom,  he  experienced  much  pain  on  ejacu- 
lation, and  this  pain  generally  persisted  as  a  soreness 


206  MALE  SEXUAL    ORGANS. 

for  several  days  afterward.  He  thought  also  that  he 
threw  off  very  little  semen  during  intercourse,  for  at 
times  he  would  awake  just  at  the  termination  of  a  dream 
where  he  had  experienced  all  the  sensations  attendant 
on  an  involuntary  emission  and  find  that  nothing  had 
been  ejaculated.  At  times  a  copious  urethral  discharge, 
unattended  by  pain  or  any  urethral  or  vesical  symp- 
toms, would  appear  suddenly,  and  then  after  an  interval 
disappear  suddenly,  rarely  yielding,  however,  to  any  of 
the  treatments  especially  directed  toward  it.  Within 
the  last  year  or  two  the  patient  had  suffered  from 
mental  depression  and  inability  to  apply  himself.  His 
leo-s  also  had  felt  weak,  and  he  had  been  unable  to  walk 
much,  or,  in  fact,  to  make  any  special  effort,  without 
great  fatigue  and  feelings  of  exhaustion,  from  which  it 
took  him  several  days  to  recover.  Every  now  and  then 
he  was  laid  up  for  a  day  or  two  by  severe  neuralgic 
headaches  or  by  sharp  neuralgias  in  connection  with 
other  parts.  He  had  been  treated  for  stricture  by 
sounds,  etc.,  but  such  treatment  had  always  made  him 
worse.  It  had  also  been  suspected  that  he  had  ataxia. 
On  making:  a  vesicular  examination  the  author  found 
both  sacs  atonic  and  very  much  distended,  their  walls 
thickened,  and  the  perivesicular  tissues  involved.  Much 
material  was  forced  out  as  a  result  of  the  stripping. 
The  vesicles  were  extremely  tender  to  pressure,  the 
patient  almost  fainting.  The  prostate  was  not  enlarged. 
The  prognosis  in  this  case,  owing  to  the  age  of  the 
patient  and  the  chronicity  of  the  disease,  was  naturally 
guarded.  j\Tow,  however,  at  the  end  of  nine  months  of 
treatment,  he  is  very  much  better.  His  sexual  force  is 
fair,  and  there  is  no  pain  on  ejaculation.  In  fact,  he 
experiences  pleasure  and  relief  from  the  act.  The  ves- 
ical and  perineal  pain  are  present  only  occasionally,  and 


ILLUSTRATIVE  INSTANCES.  207 

then  in  a  mild  degree.  He  does  not  need  his  rubber 
cushion  except  occasionally,  and  frequently  forgets  to 
take  it  with  him,  although  the  thought  of  the  pain  he 
formerly  had  makes  him  wish  to  have  his  cushion  with 
him  for  a  safeguard.  His  legs  are  stronger,  and  he  can 
walk  much  better.  He  can  also  apply  his  mind  without 
fatigue.  His  vesicles  have  improved  very  much — they 
are  but  little  distended  and  have  much  muscular  tone. 
The  indurations,  however,  both  in  connection  with  their 
walls  and  the  perivesicular  tissues,  have  not  as  yet  been 
absorbed  as  much  as  may  be  expected,  and  the  treat- 
ment will  be  continued  for  a  time. 

CASE  XVII.  Chronic  Seminal  Vesiculitis,  starting  first 
as  a  Simple  Inflammation,  aggravated  afterward  by  a  Gon- 
orrhoea. Pain  in  testicles.  Pain  along-  the  penis  and  above 
pubes.  Peelings  of  coldness  and  numbness  of  the  penis. 
Sexual  excitability  and  weakness.  Chronic  urethral  dis- 
charge. Seminal  material  at  meatus  as  a  result  of  straining 
at  stool.  A  thin,  naturally  nervous  man,  aged  twenty- 
five  years.  From  sixteen  to  twenty  years  of  age  he 
had  overindulged  sexually.  At  the  age  of  twenty  years 
he  began  to  have  severe  pains  in  the  testicles  associated 
with  some  sexual  weakness  and  numerous  nocturnal 
emissions.  A  surgeon  on  examining  him  discovered  a 
small  varicocele  on  the  left  side,  and  to  this  the  pain  in 
the  testicles  was  ascribed.  The  varicocele  was  accord- 
ingly operated  on  and  cured,  but  still  the  pain  persisted, 
and  the  patient  concluded  that  the  operation  had  been 
wrongly  done.  Another  surgeon  opened  the  wound  and 
removed  an  encysted  silk  ligature,  thinking  that  the 
ligature  by  compressing  a  nerve  might  account  for  the 
pain.  The  pain  still,  however,  persisted.  At  the  age 
of  twenty-one  years  he  contracted  a  gonorrhoea,  which 


208  MALE  SEXUAL  ORGANS. 

up  to  the  time  of  his  consulting  the  author  no  one  had 
been  able  to  cure.  He  had  been  cut  internally  for 
stricture,  and  had  had  large  sounds  used.  The  dis- 
charge, however,  persisted,  and  the  pain  in  the  testicles 
gradually  increased,  so  at  last  he  was  unable  to  work. 
He  had  also  become  so  sexually  weak  as  to  be  impotent. 
His  urination  was  quite  frequent  and  painful.  There 
was  more  or  less  free  pus  in  the  urine,  besides  a  per- 
sistent urethral  discharge.  He  was  upset  mentally. 
The  least  mental  effort  would  throw  him  into  a  free, 
cold  perspiration.  On  straining  at  stool  a  large  amount 
of  glairy  material  generally  appeared  at  the  meatus.  He 
also  often  had  a  severe  pain  above  the  pubes,  generally 
associated  with  feelings  of  vesical  tenesmus.  For  some 
time  he  had  complained  that  his  penis  was  cold,  shrunken, 
and  numb.  In  fact,  oftentimes  on  feeling  the  organ 
sensation  was  so  wanting  that  he  described  it  by  stating 
that  the  penis  did  not  feel  as  if  it  belonged  to  him. 
Both  vesicles  were  found  to  be  much  distended  and 
without  muscular  tone.  The  walls,  however,  were  but 
little  thickened,  and  there  was  no  perivesicular  involve- 
ment. This,  taken  with  the  age  of  the  patient,  made 
the  prognosis  very  good.  As  the  result  of  three  months' 
treatment  the  patient  went  home  well,  married,  and  has 
remained  in  good  condition. 

CASE  X~VTII.  Chronic  Vesiculitis  due  to  Gonorrhoea. 
A  profuse  persistent  discharge  almost  the  only  symptom  of 
the  disease.  G-onorrhceal  rheumatism.  This  case  was  taken 
from  the  author's  published  list,  in  his  article  already  re- 
ferred to,  on  persistent  urethral  discharges.  "A  man,  aged 
twenty-nine  years,  contracted  gonorrhoea  a  year  and  a 
half  before  consulting  me.  During'  all  this  time  he  had 
had  a  very  abundant  purulent  discharge  and  much  free 


ILLUSTRATIVE  INSTANCES.  209 

pus  in  the  urine.  In  fact,  at  the  time  of  the  first  con- 
sultation the  discharge  was  as  free  as  one  would  expect 
to  encounter  in  the  acute  suppurative  stage  of  the  dis- 
ease. Besides  this  he  had  gonorrhceal  rheumatism, 
which  had  centred  in  the  right  knee.  He  had  tried 
internal  remedies,  together  with  anterior  and  deep  in- 
jections, all  to  no  purpose.  I  examined  his  urethra 
carefully.  There  was  no  stricture  and  only  moderate 
tenderness.  There  was  nothing,  indeed,  to  be  discovered 
in  the  condition  of  the  urethra  to  account  for  the  ex- 
cessive discharge.  Rectal  examination  showed  the  left 
vesicle  to  be  very  much  distended,  it  being  about  the 
size  of  a  hen's  egg-  The  peri  vesicular  tissues  were 
indurated  and  inflamed,  and  the  entire  region  was  quite 
sensitive,  a  little  pressure  giving  rise  to  much  pain. 
On  making  such  pressure  considerable  fluctuation  could 
be  detected,  and  upward  of  a  drachm  of  purulent  vesic- 
ular fluid  containing  many  lifeless  spermatoza  dripped 
from  the  meatus  as  the  result,  This  consultation  took 
place  in  June,  1892.  My  opinion  at  the  time  was  that 
extirpation  of  the  purulent  vesicle  would  probably  be 
required  in  order  to  effect  a  cure,  as  the  case  seemed 
most  aggravated.  Still  I  decided  to  make  a  trial  of 
stripping  the  vesicle.  At  the  end  of  a  week  the  case 
reported  again  for  examination.  The  vesicle  at  that 
time  was  not  so  tense  as  before,  and  no  disagreeable 
reaction  had  followed  the  first  treatment.  Feeling  en- 
couraged by  these  results,  I  sent  the  patient  home  with 
instructions  to  his  medical  attendant  prescribing  a  con- 
tinuance of  the  treatment.  Early  in  September  the 
patient  returned  and  reported  that  he  was  no  better. 
On  examination  the  condition  of  the  vesicle  was  found 
to  be  exactly  as  when   first  examined.     On  stripping 

14 


210  MALE  SEXUAL  ORGANS. 

the  sac  a  great  quantity  of  the  purulent  fluid  was  dis- 
charged. The  patient  told  me  that  his  regular  attendant 
had  never  succeeded  in  squeezing  out  anything  as  the 
result  of  his  manipulations.  The  consent  of  the  medical 
gentleman  in  charge  was  then  readily  given  me  to  con- 
tinue the  treatment  myself.  After  this  the  patient 
reported  regularly  once  in  a  week  to  ten  days.  The 
intervals  between  treatment  were  a  little  too  long,  but 
were  as  frequent  as  the  patient  could  arrange.  Under 
this  systematic  treatment  progressive  improvement  en- 
sued. In  a  little  over  two  months'  time  the  discharge 
from  the  urethra  ceased  and  the  urine  became  clear. 
The  material  pressed  out  from  the  vesicle  lost  its  puru- 
lent character  and  became  viscid  and  somewhat  gelat- 
inous. The  vesicular  tenderness  and  the  perivesicular 
induration  also  gradually  disappeared.  The  vesicle, 
however,  still  remained  distended,  with  its  muscular 
walls  flabby.  On  this  account  it  seemed  very  probable 
that  a  relapse  might  occur  should  treatment  be  sus- 
pended. Accordingly  treatment  was  continued  for  about 
six  months  longer,  although  during  this  latter  interval 
the  visits  did  not  average  so  frequent  as  at  first,  often- 
times the  patient  being  seen  but  twice,  and  on  one 
occasion  but  once,  during  a  month.  At  the  end  of  this 
time  the  pouchy  condition  of  the  vesicle  had  disap- 
peared, and  the  organ  was  able  to  empty  itself  as  the 
result  of  seminal  emissions.  Since  suspending  treat- 
ment this  case  has  reported  occasionally  in  order  to  be 
assured  that  everything  is  all  right.  The  vesicle  is  now 
performing  its  functions  perfectly.  It  is  normal  to  the 
feel,  and  nothing  can  be  squeezed  out  of  it.  There  has 
been  no  return  of  the  urethral  discharge,  and  the  urine 
is  perfectly  clear." 


ILL  USTRA  TLYE  INSTANCES.  211 

CASE  XIX.  Chronic  Seminal  Vesiculitis  due  to  Gonor- 
rhoea, the  only  Subjective  Symptom  being  a  Profuse  Per- 
sistent Urethral  Discharge.  This  case  also  "was  taken  from 
the  author's  published  list,  as  was  No.  XVIII.  "  A  man, 
aged  thirty  years,  consulted  me  for  a  urethral  discharge 
which  had  been  so  profuse  for  the  preceding  six  months 
as  to  saturate  several  cloths  daily.  For  over  a  year 
before  the  present  profuse  discharge  commenced  there 
had  been  more  or  less  gleet,  which  had  become  quite 
troublesome  after  alcoholic  excess.  There  was  an  early 
history  of  several  gonorrhoeas,  which  had  apparently 
occasioned  only  temporary  inconvenience.  The  pecu- 
liarity of  the  present  muco-purulent  discharge  was  that, 
although  very  profuse,  it  was  not  accompanied  by  any 
urethral  pain  or  vesical  disturbance ;  in  fact,  the  patient 
stated  that  he  felt  perfectly  well  in  every  way,  the 
presence  of  the  discharge  being  his  only  discomfort. 
There  was  considerable  free  pus  in  both  the  first  and 
second  flow  of  urine.  Numerous  anterior  injections 
had  been  tried,  many  of  which  would  hold  in  check  the 
anterior  discharge  so  long  as  employed,  but  as  soon  as 
discontinued  the  discharge  would  reappear.  On  com- 
mencing to  treat  this  patient  I  tried  deep  urethral  in- 
stillations of  nitrate  of  silver.  The  discharge  and  most 
of  the  free  pus  in  the  urine  would  disappear  for  about 
twenty-four  hours  after  each  of  these  treatments,  at  the 
end  of  which  time  there  would  be  a  sudden  relapse  to 
former  conditions.  Examination  of  the  urethra  showed 
an  absence  of  lesions  sufficient  to  account  for  the  dis- 
charge. Attention  was  then  called  to  the  vesicles, 
although,  as  has  been  stated,  there  were  no  subjective 
symptoms  pointing  to  those  organs.  The  left  vesicle 
was  found  to  be  much  distended  and  rather  tender. 
There  was,  however,  but  little  perivesicular  infiltration. 


212  MALE  SEXUAL  ORGANS. 

A  large  amount  of  purulent  vesicular  fluid  was  squeezed 
out.  This  case  Avas  treated  continuously  by  stripping* 
the  vesicle  once  in  five  to  seven  days  for  six  weeks. 
There  was  then  marked  improvement  in  the  volume  of 
the  discharge,  and  also  in  the  condition  of  the  vesicle. 
At  this  time,  however,  the  vesicle  began  to  become 
tender  to  the  touch,  and  the  strippings,  which  had 
latterly  caused  no  discomfort,  became  somewhat  painful. 
The  material  squeezed  out,  which  had  lost  its  purulent 
character,  began  again  to  show  free  pus.  In  fact,  I 
found  that  my  treatment  had  been  a  little  too  vigorous. 
After  seeing  him  a  few  more  times  and  stripping 
gently,  as  the  vesicle  still  remained  tender,  though  not 
much  distended,  the  patient  was  sent  off,  and  the  treat- 
ment discontinued  for  the  time  being.  He  went  away 
on  a  three  months'  trip.  At  the  end  of  that  time  he 
reported  for  examination.  He  stated  that  he  was  well, 
and  had  been  wholly  free  from  all  discharge  for  the  last 
two  months — ever  since,  in  fact,  the  soreness  occasioned 
by  the  strippings  had  disappeared.  Latterly  he  had 
been  drinking  and  knocking  about  with  women,  no  dis- 
agreeable after-effects  resulting.  Rectal  examination 
showed  the  vesicles  to  be  normal." 

In  this  case  the  local  treatment,  although  efficacious, 
had  been  a  little  too  severe. 

CASE  XX.  Chronic  Seminal  Vesiculitis  probably  due  to 
Gonorrhoea.  No  subjective  symptoms.  The  individual 
thought  himself  well  until  rejected  by  a  life  insurance  com- 
pany. A  little  free  pus,  a  few  deep  urethral  shreds,  and  a 
mere  trace  of  albumin  in  the  urine.  A  man,  aged  thirty 
years,  very  strong  and  healthy,  had  gonorrhoea  six  or 
seven  years  ago,  which  persisted  as  a  gleet  for  over  a 
year,  but  which  finally  disappeared.     Since  that  time  he 


ILL  USTRA  TIVE  INSTANCES.  213 

had  thought  himself  well.  About  a  year  and  a  half 
ago  he  married.  He  was  all  right  sexually.  Just  pre- 
vious to  his  consulting  the  author  he  had  endeavored  to 
get  his  life  insured,  but  had  been  rejected  on  the  ground 
that  there  was  something  wrong  with  his  urine.  On 
examination  the  urine  was  found  to  contain  a  small 
amount  of  free  pus,  some  deep  urethral  shreds,  an  ab- 
normal amount  of  mucus,  and  a  faint  trace  of  albumin. 
The  urethra  was  examined  and  one  .small  granular  spot 
in  the  bulbous  region  detected.  This  was  easily  cured, 
but  by  so  doing  the  character  of  the  urine  was  not 
improved.  A  digital  rectal  examination  was  then  made 
and  a  chronic  inflammation  of  both  the  vesicles  dis- 
covered. The  sacs  were  but  little  distended,  though 
their  walls  were  considerably  indurated.  The  parts 
were  not  nearly  so  sensitive  to  the  first  exploration  as 
one  would  expect  to  find  them.  A  moderate  amount  of 
material  was  pressed  out  of  the  sacs,  the  urine  passed 
directly  after  the  manipulation  being  much  more  cloudy 
and  purulent  than  usual.  After  a  few  treatments  the 
urine  became  much  clearer  than  it  had  been,  and  it  bids 
fair  after  a  short  course  of  treatment  to  get  entirely 
clear  and  free  from  shreds.  In  this  case  there  were  no 
bacteria  in  the  urine  and  no  bacterial  infection  of  the 
vesicles.  The  patient  is  of  a  phlegmatic,  easy-going 
disposition,  which  fact  possibly  in  a  measure  accounts 
for  the  absence  of  subjective  symptoms. 

CASE  XXI.  Chronic  Seminal  Vesiculitis  due  to  Gonor- 
rhoea. Frequent  urination.  Perineal  tenderness.  Bacteria 
always  present  in  the  urine,  together  with  a  trace  of  al- 
bumin. Increased  sexual  desire.  A  man,  aged  forty-four 
years,  mentally  active  and  of  good  physique,  contracted 
gonorrhoea  five  years  ago.  The  gonorrhoea  proved  very 
stubborn ;  and  a  year  and  a  half  after  its  commence- 


214  MALE  SEXUAL   ORGANS. 

ment,  a  gleety  discharge  persisting,  the  surgeon  in  at- 
tendance at  the  time  endeavored,  as  was  natural,  to 
effect  a  cure  by  the  passage  of  sounds.  On  one  occa- 
sion, after  the  passage  into  the  bladder  of  a  large-sized 
instrument,  the  patient  was  shortly  afterward  seized 
with  a  violent  chill,  associated  with  vesical  tenesmus. 
This  was  followed  by  an  attack  of  cystitis,  so-called, 
and  double  epididymitis.  Since  that  time,  although 
the  gleety  discharge  stopped,  the  patient  has  always 
been  afflicted  with  frequent  and  urgent  urination.  He 
has  to  get  up  once  or  twice  at  night,  and  during  the 
day  is  often  called  upon  to  urinate  every  fifteen  or 
twenty  minutes,  though  when  he  is  mentally  absorbed 
the  interval  between  the  acts  may  be  two  or  three  hours. 
There  are  constant  pain  and  tenderness  in  the  perineum, 
together  with  similar  sensations,  although  these  are 
intermittent,  in  his  testicles.  He  also  at  times  has  pain 
in  the  lower  back.  Since  the  chill  his  urine  has  never 
been  clear.  For  some  time  afterward  it  was  purulent, 
but  gradually  the  free  pus  disappeared,  leaving  a  per- 
manent turbidity,  which  had  been  examined  on  numerous 
occasions  and  found  to  be  due  to  bacteria.  Associated 
with  this  bacterial  condition  was  a  trace  of  albumin. 
He  had  been  told  that  he  was  suffering  from  pyelitis. 
No  casts,  however,  had  ever  been  found  in  his  urine, 
although  repeated  and  skilful  searches  had  been  made 
for  them.  Sexually  he  believed  himself  to  be  all  right, 
though  his  sensations,  so  he  thought,  led  him  to  over- 
indulgence at  times.  As  his  sensations,  history,  and 
symptoms,  in  the  author's  mind,  pointed  to  seminal 
vesiculitis  rather  than  to  pyelitis  from  an  ascending 
infection,  an  examination  of  the  vesicles  was  made. 
Both  of  them,  and  especially  the  right,  were  found 
chronically  inflamed,  distended,  with  thickened  walls, 


ILL  USTEA  TIVE  INSTANCES.  215 

and  imbedded  in  an  extensive  perivesiculitis.  The  urine 
passed  immediately  after  the  stripping  was  found  to  be 
loaded  many  times  its  usual  amount  with  bacteria.  The 
customary  percentage  of  albumin  was  also  increased. 
The  urine,  however,  passed  some  time  later  in  the  day 
contained  an  abnormally  small  amount  of  bacteria,  and 
was,  in  fact,  quite  clear.  ~No  former  treatment  directed 
toward  his  kidneys  had  ever  perceptibly  reduced  the 
bacteria.  As  a  result  of  the  stripping  treatment,  in  less 
than  two  months'  time  the  urine  became  perfectly  clear 
and  the  albumin  entirely  disappeared.  The  perineal  and 
testicular  tenderness  also  markedly  decreased,  and  the 
urination  was  not  so  urgent  or  so  frequent  as  formerly. 
Shortly  after  this  time  the  case  passed  from  observation. 
Considering  the  age  of  the  patient  and  the  extent  of  the 
disease,  the  treatment  should  have  been  continued  much 
longer,  in  order  not  only  to  insure  a  thorough  removal 
of  the  symptoms  complained  of,  but  also  to  guard 
against  a  relapse  back  to  the  condition  existing  before 
the  commencement  of  the  stripping  treatment.  The 
treatment  employed,  however,  served  positively  to  ex- 
clude the  kidneys  as  a  source  or  seat  of  disease.  When 
the  patient  became  convinced  of  this  fact  he  experienced 
so  much  mental  relief  that  he  was  content,  apparently, 
to  endure  his  vesiculitis. 

CASE  XXII.  Chronic  Seminal  Vesiculitis  due  to  Gon- 
orrhoea. Persistent  severe  pain  for  years  in  the  right  groin. 
Later  on  persistent  and  painful  priapism.  Severe  pain 
and  tenderness  in  the  right  testicle.  Inability  to  sleep 
owing-  to  his  sufferings.  Numerous,  varied,  and  severe  sur- 
gical operations  undertaken  to  relieve  existing  symptoms, 
with  no  beneficial  results.  A  man,  aged  thirty-three 
years,  slight,  naturally  nervous,  but  capable  of  much 


216  MALE  SEXUAL  ORGANS. 

endurance,  had  gonorrhoea  about  five  years  ago  and  has 
never  been  right  since.  After  running  apparently  an 
ordinary  course  the  urethral  discharge  stopped  and  the 
urine  became  clear.  At  that  time,  however,  seminal 
emissions  became  frequent  and  troublesome,  and  a  pain 
appeared  in  the  right  groin.  After  sexual  excitement 
this  pain  got  worse.  On  the  theory  that  the  pain  in  the 
groin  was  due  to  a  deep  urethral  reflex,  deep  urethral 
injections,  sounds,  etc.,  were  tried.  Instead  of  relieving 
the  patient,  however,  these  treatments  seemed  to  make 
him  worse.  Perineal  section,  combined  with  bladder 
drainage,  was  after  a  time  tried.  This,  however,  not 
only  did  no  good,  but  apparently  aggravated  the  pain 
in  the  groin.  Then,  after  a  time,  one  or  more  of  the 
lymphatic  glands  in  the  right  groin  were  removed. 
The  patient,  however,  became  much  worse.  Not  only 
did  the  pain  referred  to  the  groin  persist  in  an  aggra- 
vated form,  but  also  persistent  and  painful  priapisms 
developed,  together  with  great  pain  and  tenderness  in 
the  right  testicle.  So  severe  did  these  latter  symptoms 
become  that  contact  with  the  clothing  could  not  be 
endured,  and  a  shield  had  consequently  to  be  worn. 
Then  for  some  reason,  which  from  the  patient's  descrip- 
tion was  not  clear,  suprapubic  cystotomy  and  drainage 
in  that  direction  were  resorted  to.  No  benefit  followed 
this  last  procedure.  In  fact,  symptoms  previously  com- 
plained of  were,  if  anything,  worse  afterward.  Then 
the  patient  for  a  long  period  resorted  to  a  rough  out- 
door life,  on  the  ground  that  all  his  symptoms  were 
of  a  reflex  nature.  At  this  time  his  sleep  was  much 
disturbed,  and  he  became  melancholy  and  depressed. 
This  mode  of  life  not  effecting  a  cure,  further  advice 
being  sought,  the  author  was  consulted.  The  symp- 
toms of  the  case  pointing  toward  the  seminal  vesicles, 


ILL  USTBA  Tl  VE  INSTANCES.  217 

these  organs  received  prompt  attention.  The  examina- 
tion showed  the  rig;ht  sac  to  be  the  seat  of  an  extensive 
chronic  inflammation.  It  was  very  tender  and  much 
distended.  There  were  considerable  induration  and  thick- 
ening of  the  vesicular  walls,  and  an  extensive  perive- 
sicular  induration.  The  left  sac  was  but  little  affected. 
On  stripping  the  right  sac  great  pain  was  experienced, 
all  the  existing  reflex  sensations  being  for  the  moment 
markedly  intensified.  Much  thickened  gelatinous  ve- 
sicular material  was  expressed,  rusty  colored,  due  to 
an  admixture  with  blood.  The  vesicular  bleeding, 
however,  was  not  recent,  as  the  color  indicated.  After 
a  number  of  strippings  the  bloody  element  has  disap- 
peared from  the  fluid  expressed  from  the  sac,  the  peri- 
vesiculitis  is  beginning  to  soften  and  to  be  absorbed, 
and  the  subjective  symptoms  are  lessening,  much  gen- 
eral comfort  being  usually  experienced  for  the  two  days 
succeeding  each  stripping.  The  author  has  no  doubt 
that  he  can  wholly  relieve  this  patient,  since  the  dis- 
ease is  confined  to  one  organ,  and  since  the  age  of  the 
individual  is  favorable.  In  one  sense  it  would  have 
been  better  to  have  left  the  case  from  this  list,  since  it 
is  not  as  yet  cured.  Still  the  history  is  of  such  interest 
that  it  was  thought  best  to  incorporate  it  here,  even 
though  the  treatment  is  at  present  so  incomplete.  The 
patient  states  that  he  shall  insist  on  extirpation  of  the 
offending  vesicle  if  the  present  method  of  treatment  is 
not  curative.  The  author,  however,  has  no  expectation 
of  having  to  resort  to  this  extreme  measure. 

CASE  XXIII.  Chronic  Seminal  Vesiculitis  originating 
in  Gonorrhoea.  Constant  sexual  desire  unattended  with 
satisfaction.  Great  mental  depression.  Insomnia.  Quar- 
relsomeness.    A  painful   spot  in  the  urethra.     Pain  in  the 


218  MALE  SEXUAL  ORGANS. 

testicles.  Surgical  operation  for  varicocele,  followed  by  no 
relief.  A  man  of  fine  physique,  aged  thirty-four  years. 
Had  gonorrhoea  many  years  ago,  but  apparently  got 
over  it  after  a  time.  For  the  last  few  years  he  had  had 
a  sensation  as  if  he  were  losing  semen,  and  after  strain- 
ing at  stool  thick,  pasty  material  appeared  at  the  meatus. 
He  also  suffered  from  a  nao-g-ino-  sexual  desire,  associated 
latterly  with  great  sexual  weakness.  He  got  little  or 
no  satisfaction  from  coitus.  In  order  to  insure  an  erec- 
tion sufficient  to  accomplish  the  act  he  used  to  drink 
freely  of  Bass's  ale.  His  urine  was  clear,  and  he  had 
no  frequency  of  urination.  There  was  always  a  sensa- 
tion as  if  there  were  a  raw  spot  in  the  urethra.  This 
sensation  was  so  persistent  that  his  mind  became  fixed 
upon  it.  He  imagined  all  sorts  of  causes  for  the  sensa- 
tion, and  became  morose.  After  a  time,  besides  the  pain 
in  the  urethra,  the  testicles  also  became  painful.  A 
varicocele  was  detected  on  the  left  side,  and  it  was 
operated  upon.  No  relief  Avas,  however,  experienced 
from  the  operation,  and  the  patient  concluded  that  it 
had  not  been  thoroughly  done.  He  then  became  sleep- 
less at  night  and  resorted  to  considerable  alcoholic 
stimulation  in  order  to  get  rest.  He  was  so  quarrelsome 
that  he  continually  got  into  trouble  with  his  family  and 
business  associates.  He  was  looked  upon  generally  as 
a  crank.  He  finally  sought  the  author  to  see  if  a 
thorough  operation  on  his  varicocele  could  not  be  as- 
sured him.  Both  vesicles  were  found  to  be  exquisitely 
tender,  much  distended,  and  moderately  thickened. 
There  was,  however,  but  little  perivesiculitis.  A  course 
of  strippings  was  commenced,  and  the  alcoholic  stimu- 
lation stopped  and  much  exercise  prescribed,  no  sexual 
intercourse  or  excitement,  of  course,  being  allowed. 
After  a  few  months  the  sensation  in  the  urethra  dis- 


ILL  US  TEA  TI VE  INSTANCES.  2 1 9 

appeared,  natural  sleep  returned,  and  the  nagging  sexual 
desire  disappeared.  He  stated,  in  fact,  that  he  had  no 
desire  at  all,  and  felt  as  if  he  might  be  impotent.  He 
was  assured,  however,  that  the  feeling  of  impoteticy  was 
not  real,  and  on  no  account  was  he  allowed  to  make  a 
trial  of  his  sexual  capacity.  Since  that  time,  the  treat- 
ment being  continued,  all  his  old  symptoms  have  dis- 
appeared or  have  become  so  slight  as  not  to  cause  him 
annoyance,  and  he  is  well  satisfied  with  his  condition. 
The  vesicles  also  have  markedly  improved,  and  are,  in 
fact,  nearly  well. 

CASE  XXIV.  Chronic  Seminal  Vesiculitis,  Non-gonor- 
rhoeal,  Non-tubercular.  Neiirotic  and  some  mental  disturb- 
ances. Feelings  of  impotency.  A  man,  aged  twenty-five 
years,  strong  and  vigorous.  Xever  had  gonorrhoea. 
Soon  after  puberty  he  masturbated  to  a  considerable 
extent  until  he  was  twenty-one,  after  which  time  he 
indulged  himself  sexually  and  stopped  the  practice  of 
masturbation.  For  a  number  of  years  he  had  been  very 
nervous,  but  otherwise  he  thought  himself  all  right. 
Less  than  a  year  before .  the  time  of  consulting  the 
author  he  had  fallen  in  love  with  a  young  woman  and 
had  engaged  himself  to  marry  her.  Since  that  time  he 
had  changed  his  former  mode  of  life  and  had  ceased 
indulging  himself  sexually.  After  being  engaged  a  few 
months  his  troublesome  symptoms  commenced.  These 
consisted  of  an  entire  loss  of  erectile  power  associated 
with  sensations  of  impotency,  severe  headaches  after 
mental  efforts,  tremulousness,  and  inability  to  control 
his  emotions.  He  was  also  troubled  much  by  a  general 
itching  sensation,  particularly  marked  in  the  neighbor- 
hood of  the  eyes.  He  was  very  despondent  and  de- 
pressed.    Examination  showed  the  seminal  vesicles  to 


220  MALE  SEXUAL  ORGANS. 

be  both  extremely  distended,  but  soft  and  non-indurated. 
They  were  also  very  tender.  A  great  quantity  of  ve- 
sicular material,  slightly  purulent,  was  forced  out  as 
the  result  of  the  stripping,  leaving  the  sacs  collapsed 
and  atonic.  The  prognosis  in  this  case  was  extremely 
good,  owing  to  the  simple  character  of  the  inflamma- 
tion, to  the  age  of  the  patient,  and  to  the  non-indurated 
condition  of  the  vesicle  Avails  and  surrounding  tissues. 
Now,  as  the  result  of  less  than  four  months  of  treatment, 
the  patient  is  well.  His  mental  and  neurotic  symptoms 
were  the  first  to  disappear.  His  vesicles  have  regained 
their  tone,  and  are  firm  and  contracted  to  the  feel,  almost 
nothing  being  forced  from  them  as  a  result  of  the  strip- 
ping. 

CASE  XXV.  Chronic  Seminal  Vesiculitis,  Non-g-onor- 
rhceal,  Non-tubercular.  Melancholia.  Neurotic  disturbances. 
Feeling-s  of  inipotency.  Claimed  never  to  have  had  sexual 
intercourse.  Atrophy  of  a  testicle.  A  man,  aged  twenty- 
eight  years,  slender,  naturally  quiet  and  studious ;  had 
been  brought  up  under  very  moral  influences ;  denied, 
apparently  with  truth,  that  he  had  ever  indulged  himself 
sexually.  No  history  of  masturbation.  Had  never  taken 
but  little  physical  exercise,  preferring  to  occupy  himself 
with  books.  As  long  as  fifteen  years  ago  his  father, 
noticing;  a  varicocele  on  the  left  side,  had  had  a  sus- 
pensory  bandage  applied,  and  this  had  been  worn  ever 
since.  Some  years  ago  the  young  man  began  to  com- 
plain of  pain  in  the  testicles  of  a  neuralgic  character. 
This  persisting,  the  varicocele  was  operated  upon  and 
removed.  He  got  no  relief,  however,  from  the  operation; 
in  fact,  the  confinement  in  bed  subsequent  to  it  was  not 
well  borne.  He  lost  much  flesh.  The  pains  in  the  testicles 
were  much  increased,  and  numerous  new  and  trouble- 


ILL  USTBA  Tl  VE  INSTANCES.  221 

some  symptoms  then  appeared;  among  these  were  a 
complete  loss  of  erectile  power  and  penile  sensations, 
such  as  pain  along  the  urethra,  numbness  and  coldness 
of  the  organ.  He  became  very  nervous,  despondent, 
and  imaginative.  He  was  fearful  of  going  crazy.  He 
could  no  longer  devote  himself  to  books,  but  sat  moping 
all  the  time.  Within  a  year  or  so  after  the  operation  for 
varicocele  the  left  testicle  completely  atrophied.  The 
patient  naturally  ascribed  the  atrophy  of  the  organ  to 
the  operation,  but  whether  rightly  or  not  is  a  question. 
About  three  years  after  the  varicocele  operation  the 
author  was  consulted.  Both  vesicles  were  found  to  be 
in  an  extreme  state  of  distention ;  the  walls  were  some- 
what indurated ;  on  stripping  them  the  patient  cried  out 
and  became  markedly  hysterical.  After  a  compara- 
tively short  treatment,  however,  a  great  improvement 
in  symptoms  resulted,  the  mental  and  neurotic  ones 
being  the  first  to  disappear.  The  patient  expressed 
himself  as  satisfied  with  his  condition,  and  disappeared 
before  resolution  sufficient  to  satisfy  the  author  had 
taken  place  in  the  vesicles.  The  organs  had  apparently 
regained  their  muscular  tone,  but  some  induration  of  the 
walls  still  persisted.  It  was  interesting  to  note,  how- 
ever, that  the  left  vesicle  and  the  left  portion  of  the 
prostate  did  not  seem  to  be  in  the  least  atrophied  or 
affected  by  the  atrophy  of  the  left  testicle. 

CASE  XXTT.  Chronic  Seminal  Vesiculitis  due  to  Gon- 
orrhoea. A  relapsing-  discharge.  Atrophy  of  the  right  testicle 
corresponding  to  the  vesicle  chiefly  involved.  Few  sub- 
jective symptoms.  A  man,  aged  thirty  years,  of  rather 
poor  physique.  His  circulation  had  always  been  poor. 
His  hands  were  blue,  and  he  got  out  of  breath  easily. 
As  he  had  always  been  so  affected,  he  may  have  had  a 


222  MALE  SEXUAL  ORGANS. 

congenital  malformation  of  the  heart.  He  had  had 
gonorrhoea  several  times.  He  had  had  an  epididymitis 
in  connection  with  the  right  testicle  twice,  and  after  the 
second  attack  the  organ  completely  atrophied.  He  was 
first  seen  by  the  author  about  two  years  after  this 
atrophy.  At  that  time  he  was  suffering  from  a  profuse 
discharge,  which,  however,  gave  him  little  pain.  This 
followed  a  vigorous  attempt  at  coitus  while  wearing  a 
very  tight-fitting  India-rubber  condom,  and  was  con- 
sequently due  to  the  effect  of  an  irregular  act  with  a 
damaged  sexual  apparatus  rather  than  to  a  contamina- 
tion. Under  treatment  the  discharge  readily  disap- 
peared and  the  urine  became  clear,  with  the  exception 
of  a  long  moulded  shred,  which  under  the  microscope 
was  seen  to  consist  of  vesicular  elements.  The  vesicles 
were  examined.  The  right  was  found  to  be  the  one 
chiefly  at  fault.  It  was  somewhat  distended,  and  the 
walls  were  much  thickened.  Considerable  purulent 
material  was  pressed  out.  The  prostate  was  not  at  all 
abnormal  to  the  feel,  and  both  lobes  were  exactly  alike 
in  size  and  consistency.  Resolution  in  the  vesicle  grad- 
ually occurred.  This  case  was  also  somewhat  remark- 
able owing  to  the  almost  entire  absence  of  subjective 
symptoms,  being  in  that  respect  similar  to  Case  XX. 

CASE  XXVII.  Chronic  Seminal  Vesiculitis  of  a  mild 
grade  in  one  who  had  never  had  sexual  intercourse,  but 
who  had  to  a  moderate  degree  practised  masturbation. 
Pains  in  the  testicles.  Loss  of  erectile  power.  Coldness 
and  apparent  want  of  circulation  in  the  penis.  A  fancy- 
that  there  had  been  a  shrinkage  in  the  size  of  the  penis. 
A  man,  aged  twenty-nine  years,  naturally  shy  and 
bashful,  had  never  had  sexual  intercourse,  although  he 
had  practised  masturbation  apparently  to  a  moderate 


ILLUSTRATIVE  INSTANCES.  223 

extent  for  many  years.  Less  than  a  year  ago  he  became 
engaged  to  marry,  and  then  for  the  first  time  he  felt  that 
there  was  something  wrong.  He  began  to  have  painful 
sensations  in  the  testicles ;  his  erectile  power  disap- 
peared ;  his  penis  felt  cold  and  clammy ;  he  imagined 
that  it  was  gradually  shrinking  in  size.  These  symp- 
toms, together  with  the  idea  that  he  would  be  incapable 
of  consummating  the  marital  act,  served  to  cause  great 
mental  depression.  The  vesicles  were  found  to  be  mod- 
erately distended  and  somewhat  thickened.  A  compara- 
tively little  treatment,  however,  served  to  correct  the 
existing  pathological  condition.  The  erectile  power  re- 
turned, the  patient  married,  and  found  himself  sexually 
competent. 

CASE  XXVTII.  Chronic  Seminal  Vesiculitis  due  to 
sexual  exertions  when  very  young-  and  to  masturbation. 
Frequent  and  persistent  emissions  both  at  night  and  by  day. 
Loss  of  mental  force.  Great  mental  depression.  A  man, 
aged  thirty-one  years,  at  the  age  of  twelve  years  or 
thereabouts  began  sexual  intercourse ;  at  fourteen  began 
to  be  troubled  by  nocturnal  seminal  emissions.  These 
emissions  gradually,  as  years  passed  by,  became  more 
and  more  troublesome,  and  at  times  they  would  occur 
during  the  day  as  the  result  of  some  excitement. 
Finally  he  lost  all  control  over  them.  They  would 
occur  without  any  erection,  while  straining  at  stool, 
while  making  a  mental  effort,  such,  for  instance,  as 
adding  a  column  of  figures,  or  as  the  result  of  any 
sudden  sensation,  as  of  joy  or  sorrow.  Very  little  sem- 
inal fluid  would  be  ejected  as  a  result  of  an  emission, 
and  sometimes  he  would  experience  the  sensation  only 
of  ejaculation,  there  being  no  flow.  He  became  very 
nervous,   sensitive,    and   depressed.      He  passed   for  a 


224  MALE  SEXUAL  ORGANS. 

crank,  and  some  even  thought  him  actually  crazy.  He 
had  been  treated  extensively  by  sounds,  deep  urethral 
injections,  and  by  methods  directed  toward  his  mental 
state.  He  had,  however,  derived  no  benefit  from  any- 
thing which  he  had  so  far  tried.  On  consulting  the 
author  an  examination  of  the  seminal  vesicles  was  made. 
The  walls  of  both  these  organs  were  found  to  be  thick- 
ened; they  were  somewhat  distended  and  surrounded 
by  a  moderate  amount  of  chronic  perivesicular  thicken- 
ing. As  a  result  of  treatment  the  vesiculitis  markedly 
improved ;  the  emissions  by  day  disappeared,  and  those 
by  night  occurred  only  at  considerable  intervals ;  he 
became  cheerful  and  capable  of  mental  effort.  Before 
it  was  advisable,  however,  he  had  to  go  to  his  distant 
home,  with  the  expectation  of  returning  in  the  near 
future  to  complete  his  course  of  treatment. 

CASE  XXIX.  Chronic  Seminal  Vesiculitis  due  to  Gon- 
orrhoea. Sexual  excitability.  Uncontrollable  emissions  by- 
day,  as  well  as  involuntary  ones  at  night.  Severe  frontal 
headaches,  especially  confined  to  the  temporal  region.  A 
man,  aged  thirty-two  years,  generally  strong  and  healthy, 
had  gonorrhoea  about  four  years  ago.  Two  years  after 
this  he  began  to  have  frequent  seminal  nocturnal  emis- 
sions. This  trouble  gradually  increased,  and  uncon- 
trollable emissions  by  day  occurred  whenever  he  saw, 
heard,  or  was  in  any  way  conscious  of  anything  tending 
in  the  least  to  excite  his  sexual  sense.  The  volume  of 
fluid  ejected  each  time  was  small,  and  sometimes  almost 
nil.  With  this  aggravated  condition  of  his  sexual 
function  severe  headaches  began  to  develop.  He  de- 
scribed them  as  located  in  the  temporal  region.  While 
they  persisted  he  could -do  no  work.  At  first  he  could 
not  account  for  them,  but  after  a  time  he  felt  that  they 


ILLUSTRATIVE  INSTANCES.  225 

were  aggravated  by  the  emissions ;  and  should  he  be- 
come sexually  excited,  then  he  was  sure  to  have  one  of 
an  especially  severe  character.  He  had  tried  all  sorts  of 
remedies  for  these  headaches,  without,  however,  deriving 
any  benefit.  In  describing  his  case  he  always  laid 
great  stress  on  his  head  troubles,  hardly  touching  on 
his  sexual  disturbances.  On  consulting  the  author  an 
examination  of  the  vesicles  was  made,  and  they  were 
found  moderately  distended,  with  their  walls  somewhat 
infiltrated.  As  the  result  of  two  months  of  the  strip- 
ping treatment  the  headaches  were  wholly  and  perma- 
nently cured.  The  emissions  were  a  little  more  stubborn, 
and  required  a  little  longer  period  of  treatment  before 
they  became  properly  regulated. 

CASE  XXX.  Chronic  Seminal  Vesiculitis  due  to  Gon- 
orrhoea. The  prominent  complaint  "was  -what  was  supposed 
to  be  repeated  attacks  of  intestinal  colic.  Sexual  weakness. 
Feelings  of  weakness  and  depression  following  emissions. 
A  man,  aged  twenty-nine  years,  had  always  been  deli- 
cate and  disinclined  to  take  hard  exercise.  About  three 
years  ago  had  a  gonorrhoea,  which  was  complicated  with 
rheumatism.  This  disease,  however,  was  apparently 
cured  after  some  months.  About  a  year  and  a  half  ago 
he  began  to  have  what  appeared  to  be  attacks  of  intes- 
tinal colic.  He  had  dieted  and  taken  various  medicinal 
courses  directed  toward  this  apparent  bowel  affection, 
but  he  had  never  felt  that  he  had  received  any  benefit 
from  what  he  had  done.  For  some  time  after  seeing 
this  case  the  author  directed  his  attention  toward  the 
bowels,  also  without  success.  It  became  noticeable, 
however,  that  the  attacks  of  pain  were  not  associated 
with  any  other  symptoms  of  indigestion,  and  that  their 
occurrence  had  no  special  reference  to  diet,  exposure  to 

15 


226  MALE  SEXUAL  ORGANS. 

cold,  etc.,  agents  which  are  generally  active  in  producing 
intestinal  colic.  As  the  result  of  considerable  investi- 
gation, it  was  found  that  sexual  weakness  existed ;  that 
seminal  emissions  were  frequent  in  spite  of  regular 
sexual  exercise,  and  that  they  were  followed  by  sensa- 
tions of  bodily  weakness  and  depression.  He  was  also 
languid  and  disinclined  to  make  mental  efforts.  The 
urine  was  normal.  Examination  of  the  seminal  vesicles 
showed  them  both  to  be  somewhat  distended,  with  mod- 
erately inflamed  and  thickened  walls.  There  was  no 
perivesiculitis.  After  a  comparatively  short  course  of 
stripping  the  so-called  colics  permanently  disappeared, 
followed  after  an  interval  by  a  restoration  of  his  sexual 
vigor. 

CASE  XXXI.  Chronic  Seminal  Vesiculitis  due  to  Gon- 
orrhoea. A  persistent  buzzing  or  ringing-  in  the  ears  and 
head  the  chief  apparent  clinical  feature.  Loss  of  semen  at 
stool.  Sexually  weak.  Premature  emission  on  attempting 
coitus.  A  man,  aged  thirty-four  years,  had  had  gonor- 
rhoea several  times  in  earlier  life.  For  some  time  he  had 
been  troubled  by  a  persistent  buzzing  or  ringing  in  the 
head  and  ears,  for  which  he  had  sought  professional 
advice  on  numerous  occasions,  without  experiencing 
relief.  Finally  he  became  interested  in  a  young  woman 
and  began  to  consider  the  question  of  marriage.  As, 
however,  he  had  felt  himself  weak  sexually  of  late,  a 
premature  emission  often  taking  place  on  attempting 
coitus,  and  as  he  had  noticed  after  straining  at  stool  a 
thick,  pasty  substance  at  the  meatus,  which  he  took  to 
be  semen,  he  thought  it  well  to  seek  advice  regarding 
his  potency  with  reference  to  marriage.  He  therefore 
visited  the  author.  A  moderate  amount  of  vesiculitis 
in  connection  with  both  sacs  was  discovered.     After  a 


ILLUSTRATIVE  INSTANCES.  227 

few  months  of  treatment  he  discovered  that  his  head 
affection  had  entirely  disappeared,  and,  as  there  was  no 
return  of  the  trouble,  it  seems  fair  to  infer  that  it  was  a 
reflex  phenomenon  dependent  on  the  vesiculitis.  The 
sexual  function  also  improved,  and  after  a  time  he  mar- 
ried and  disappeared. 

CASE  XXXII.  A  Probable  Case  of  Calculus  of  the 
Seminal  Vesicle  Lodged  in  and  Protruding  from  the  Urethral 
End  of  the  Ejaculatory  Duct.  Operated  upon  and  calculus 
removed  by  Dr.  Keyes.  Frequent  emissions  folio-wed  by 
severe  pain  before  the  operation.  After  operation  no  pain 
on  emission,  but  the  seminal  fluid  instead  of  being  ejected 
forward  flowed  backward  into  the  bladder.  A  man,  aged 
thirty-two  years,  had  for  some  time  suffered  from  urgent 
and  frequent  urination.  He  had  a  slight  urethral  dis- 
charge and  a  small  amount  of  free  pus  in  his  urine. 
His  sexual  sensations  were  intensified.  He  would  have 
times  when  priapisms  were  a  troublesome  feature.  He 
had  frequent  seminal  emissions.  The  act  of  ejaculation, 
whether  associated  with  involuntary  emissions  or  with 
coitus,  was  extremely  painful,  and  left  a  soreness  in  the 
part  for  some  time  afterward.  He  had  been  examined 
for  vesical  stone  and  none  found.  He  had  also  been 
treated  for  stricture  and  for  inflammation  of  the  deep 
urethra.  He  had  never  experienced  relief  from  any  of 
the  treatments  to  which  he  had  resorted.  He  finally 
consulted  Dr.  Keyes,  and  that  gentleman  discovered  a 
calculus  which  projected  into  the  prostatic  urethra  from 
its  floor.  This  calculus  was  firmly  fixed  in  one  spot, 
and  at  times  could  not  be  detected,  it  apparently  having 
slipped  back  into  its  nidus,  so  that  it  did  not  in  the  least 
project  into  the  urethra.  At  such  times,  however,  it  was 
found  that  if  the  forefinger  were  inserted  into  the  rectum 


228  MALE  SEXUAL   ORGANS. 

and  upward  pressure  on  the  prostatic  region  exerted, 
while  a  good-sized  blunt  steel  sound  was  passed  along 
the  prostatic  urethra,  that  the  calculus  could  always  be 
felt  by  the  sound.  Unfortunately,  this  case  occurred  a 
number  of  years  ago,  before  either  Dr.  Keyes  or  the 
author  had  directed  particular  attention  to  the  seminal 
vesicles.  Consequently  these  sacs  were  not  examined 
or  stripped.  A  perineal  section,  however,  was  made  and 
a  rough,  hard  concretion  discovered  projecting  into  the 
urethra  in  the  position  occupied  by  the  mouth  of  an 
ejaculatory  duct.  There  were  much  suppuration  and 
inflammatory  induration  of  the  tissues  about  the  con- 
cretion, which  made  it  difficult  to  map  out  exactly  its 
anatomical  situation.  It,  however,  extended  downward 
into  what  seemed  to  be  the  middle  of  the  lower  portion 
of  the  prostatic  body.  It  was  wedged  into  the  tissues 
so  that  it  was  removed  with  difficulty.  Its  shape  was 
very  irregular.  It  weighed  about  ten  grains.  After  the 
operation  the  painful  element  associated  with  the  ejacu- 
latory act  wholly  disappeared,  together  with  the  inten- 
sified sexual  sensations ;  in  fact,  he  felt  himself  some- 
what sexually  weak.  The  seminal  fluid  also  at  the  time 
of  ejaculation,  owing  to  the  injury  done  the  prostatic 
urethra  consequent  on  the  removal  of  the  stone,  instead 
of  beins:  directed  forward  flowed  backward  into  the 
bladder.  Of  course,  the  author  cannot  be  positive  that 
this  case  represented  one  of  calculus  of  the  seminal 
vesicle,  the  concretion  having  gradually  worked  its  Avay 
along  the  ejaculatory  duct,  aided  largely,  owing  to  its 
size,  by  ulcerative  processes.  Still,  the  sexual  sensa- 
tions associated  with  the  presence  of  the  calculus, 
together  with  their  disappearance  after  its  removal,  the 
new  symptoms  present  after  convalescence  from  the 
operation,  and  the  position  of  the  stone,  would  make 


ILLUSTRATIVE  IXSTAXCES.  229 

the  supposition  that  it  was  a  case  of  this  description 
most  tenable.  If  Dr.  Keyes  had  had  the  seminal 
vesicle  in  mind  while  operating,  he  would  probably  have 
been  able  at  the  time  to  make  an  actual  anatomical 
demonstration  of  the  vesicular  source  of  the  stone. 


Case  XXXIII.  Chronic  Tubercular  Seminal  Vesiculitis 
in  one  "who  had  had  Gonorrhoea.  A  persistent  urethral  dis- 
charge the  chief  clinical  feature.  A  secondary  epididymitis. 
This  case  "was  taken  from  the  author's  list  in  his  article  on 
"Persistent  Urethral  Discharges,"  etc.,  reference  to  "which 
has  already  been  made.  "  A  man,  aged  twenty-seven 
years,  had  gonorrhoea,  followed  for  more  than  a  year  by 
a  persistent  discharge.  The  patient  was  tall,  thin,  and 
strumous.  He  never  took  much  exercise,  and  spent 
little  time  out  of  doors.  Examination  of  the  urethra 
showed  it  to  be  granular  and  somewhat  strictured. 
These  conditions  yielded  to  treatment;  but  a  consider- 
able mucous  discharge  still  persisting,  the  vesicles  were 
examined.  These  sacs  were  found  to  be  slightly  tender 
and  somewhat  thickened,  a  fair  amount  of  fluid  being 
squeezed  out.  After  stripping  the  vesicles  a  few  times 
the  discharge  stopped,  and  the  patient  disappeared 
satisfied  with  his  condition.  The  feel  of  the  vesicles, 
however,  as  the  result  of  the  few  treatments  had  not 
improved.  In  about  three  months  the  patient  reap- 
peared, stating  that  after  free  sexual  indulgence  the 
discharge  had  reappeared.  The  vesicles  at  this  time, 
although  not  tender,  were  much  more  thickened  than 
when  first  observed,  the  infiltration  extending  into  the 
perivesicular  tissues  ;  the  prostate  also  seemed  firm  and 
somewhat  enlarged.  The  condition  being  considered 
tubercular  no  further  local  treatment  was  deemed  ad- 
visable at  the  time,  cod-liver  oil  and  hygienic  measures 


280  MALE  SEXUAL  ORGANS. 

being  prescribed.  A  short  time  afterward  the  tuber- 
cular process  extended  to  the  left  epididymitis,  involving 
it  in  a  characteristic  manner.  This  patient  when  last 
seen  was  improving  slowly  under  general  treatment." 

This  case  is  characteristic  of  a  larg-e  class.  Here  it 
is  observed  there  are  no  sexual  disturbances.  By  irri- 
tating the  parts,  however,  as  by  a  sound,  deep  injection, 
or  a  too  vigorous  stripping,  such  symptoms  probably 
would  be  temporarily  produced. 

CASE  XXXIV.  Subacute  Tubercular  Seminal  Vesicu- 
litis. Gonorrhoea  many  years  previously.  Tubercular  ante- 
cedents. Chief  clinical  feature  a  free  urethral  discharge, 
promptly  showing1  itself  after  sexual  excess  combined  with 
champagne.  This  case  was  also  taken  from  the  same  list 
as  Case  XXXIII.  "  A  man,  aged  thirty-four  years,  came 
for  a  discharge  two  months  old,  which  appeared  directly 
after  an  excess  of  champagne  and  sexual  intercourse. 
He  had  had  gonorrhoea  years  before.  His  urethra  had 
been  examined  for  stricture  with  negative  results.  His 
present  discharge  had  not  until  recently  caused  him  any 
pain  or  inconvenience  aside  from  its  presence.  Shortly 
before  coming  for  consultation  he  had  made  a  trial  of 
sexual  intercourse.  The  act  had  caused  him  consider- 
able pain,  and  had  aggravated  his  condition.  He  had 
received  no  benefit  from  injections.  Rectal  examination 
showed  both  the  vesicles  to  be  inflamed,  nodular,  and 
somewhat  distended.  A  few  gentle  trials  of  vesicular 
strippings  were  made,  but  had  to  be  abandoned,  as  the 
parts  became  more  nodular  and  infiltrated.  Whiskey  in 
stated  amounts  and  cod-liver  oil  were  then  prescribed, 
together  with  hygienic  measures,  all  local  treatment 
being  stopped.  The  patient,  who  before  had  been 
anaemic  and  somewhat  wasted,  speedily  improved,  both 


ILLUSTRATIVE  INSTANCES.  231 

locally  and  generally.  Xow,  at  the  end  of  three  months, 
the  vesicles,  although  a  little  distended,  have  lost  their 
nodular,  infiltrated  feel ;  and  the  discharge,  which  per- 
sists very  moderately,  has  no  longer  its  purulent  char- 
acteristics, but  has  become  watery." 

CASE  XXXV.  Chronic  Tubercular  Seminal  Vesiculitis. 
Never  had  gonorrhoea.  Pains  in  the  perineum,  and  at  times 
in  back  and  thighs.  Vesical  irritability.  Symptoms  aggra- 
vated by  sexual  intercourse.  Fever  generally  after  much 
exertion.  Much  perivesiculitis.  A  man,  aged  thirty-two 
years,  fat,  but  anaemic,  inherits  phthisical  tendencies. 
^NTever  had  gonorrhoea.  Knew  no  cause  for  his  illness. 
One  and  a  half  years  ago  he  suddenly  began  to  feel  an 
uneasy  sensation  in  the  perineum,  which  was  aggravated 
by  jolting,  walking,  nervous  fatigue,  or  by  a  full  bladder. 
Oftentimes,  also,  he  noticed  that  his  bladder  felt  irrita- 
ble, and  that  his  urination  was  frequent.  Latterly  he 
had  been  obliged  to  get  up  once  or  twice  at  night  to 
urinate.  Sexual  intercourse  if  at  all  excessive  a°'OTa- 
vated  his  symptoms.  He  had  had  numerous  feverish 
attacks,  associated  frequently  with  light  chills.  These 
generally  came  on  after  much  exercise,  especially  if  ex- 
posure to  cold  followed.  When  these  feverish  attacks 
occurred  the  pain  in  the  perineum  would  be  intensified, 
and  added  to  it  there  would  be  pain  in  the  lower  back, 
which  often  radiated  down  into  the  thighs.  These 
symptoms  had  so  weakened  him  that  he  had  been  forced 
to  quit  work.  His  appetite  had  left  him  and  his  diges- 
tion was  poor.  Such  was  his  condition  when  he  first 
reported  to  the  author.  With  the  exception  of  a  few 
shreds,  there  was  nothing  abnormal  in  the  urine.  Rectal 
exploration,  however,  revealed  the  existence  of  much 
inflammation.     The  space  beyond  the  prostate  was  so 


232  MALE  SEXUAL  ORGANS. 

filled  in  by  a  hard  inflammatory  exudation  that  it  was 
impossible  to  make  out  the  posterior  border  of  the  pros- 
tate. This  exudation  extended  backward  further  than 
the  finger  could  reach.  It  surrounded  and  imbedded 
both  seminal  vesicles.  It  also  extended  laterally  be- 
yond the  vesicles  and  bound  the  whole  post-prostatic 
space  firmly  to  the  fixed  structures  of  the  pelvis.  The 
situation  of  the  vesicles  could  be  made  out  by  the  extra 
heaping  up  about  them  of  the  inflammatory  exudate. 
The  prostate  also  was  enlarged  and  rendered  immovable 
to  pressure  by  reason  of  its  connection  with  the  exuda- 
tion. The  vesicular  region  was  not  very  sensitive  to 
pressure ;  much  less  so  than  was  usual.  Gentle  strip- 
ping at  this  time  over  the  prominences  which  marked 
the  situation  of  the  vesicles,  owing  to  the  firm,  unyield- 
ing character  of  the  inflamed  tissues,  served  to  press 
out  very  little  material  from  the  sacs.  A  few  strippings 
at  weekly  intervals  were  tried,  although  the  tubercular 
characteristics  made  it  doubtful  if  much  or  any  benefit 
would  be  derived  from  it.  After  two  or  three  strippings 
he  thought  he  was  better ;  then,  however,  he  grew  worse, 
as  evidenced  by  a  tendency  to  feverishness  and  by  severe 
pains  in  his  back  and  thighs,  as  well  as  in  the  perineum. 
The  finger  also  showed  the  parts  boggy,  oedematous,  and 
more  inflammatory  than  when  first  seen.  Thus  it  was 
evident  that  the  local  treatment  was  not  suitable  in  a 
case  of  this  description.  He  digested  cod-liver  oil 
poorly.  He  was  finally  ordered  to  Colorado,  it  being 
evident  that  if  a  cure  was  to  be  effected  it  would  have 
to  be  accomplished  by  climatic  influences.  Extirpation 
of  the  vesicles  in  a  case  of  this  nature,  owing  to  the 
extent  and  firmness  of  the  inflammatory  exudate,  would 
be  very  difficult  of  accomplishment,  and  would  certainly 


ILLUSTRATIVE  INSTANCES.  233 

not  be  entertained  until  a  trial  of  change  of  climate  had 
proved  a  failure. 

CASE  XXXYL  Chronic  Tubercular  Seminal  Vesiculitis. 
No  gonorrhoeal  antecedents.  Free  suppuration.  Pain  in  the 
rectum  and  perineum.  Great  irritability  of  the  bladder  due 
to  involvement  of  the  vesical  neck.  A  man,  aged  forty- 
nine  years,  debilitated  by  pulmonary  tuberculosis,  had 
experienced  for  some  time  pain  in  the  perineum  and 
rectum,  especially  noticeable  after  exercise  or  straining 
at  stool.  These  symptoms  were  followed  by  a  tubercular 
epididymitis  in  connection  with  the  left  testicle.  Shortly 
after  this  symptoms  of  vesical  irritability  occurred. 
There  were  no  sexual  symptoms.  The  patient  then 
came  under  the  author's  notice.  The  left  seminal  ves- 
icle to  the  rectal  feel  appeared  the  size  of  a  hen's  egg, 
soft,  and  fluctuating,  gentle  pressure  forcing  out  much 
purulent  material.  The  right  vesicle  was  infiltrated, 
rather  firm,  and  involved  to  a  very  much  less  extent 
than  the  left.  There  was  considerable  perivesiculitis, 
which  was  of  a  soft,  oedematous  nature,  and  not  sclerous 
as  in  the  preceding  case.  There  was  some  free  pus  in 
the  urine,  and  a  urethral  discharge  which  came  from  the 
deep  urethra.  Some  months  after  first  seeing  this  case 
the  tubercular  condition  became  so  marked  at  the  neck 
of  the  bladder  that  the  symptoms  of  tenesmus  and  pain 
on  urination  grew  unbearable,  and  a  suprapubic  incision 
for  urinary  drainage  in  that  direction  was  made.  Some 
comfort  was  derived  from  this  procedure,  but  death 
followed  in  a  few  months,  chiefly  due  to  the  lung-affec- 
tion. In  this  case,  when  first  seen,  if  the  condition  of 
the  lungs  had  warranted  it,  extirpation  of  the  left  semi- 
nal vesicle,  together  with  the  cord  and  epididymitis, 
might  have  done  much  good.     Such  an  operation  would 


234  MALE  SEXUAL  ORGANS. 

not,  to  be  sure,  have  removed  all  of  this  focus  of  disease, 
but  it  would  have  removed  the  most  active  portion  of  it, 
and  this  might  have  prevented  the  rest  from  extending 
so  rapidly.  Still,  even  in  an  extreme  condition  such  as 
this  was,  the  results  of  conservative  methods,  provided 
the  lungs  had  been  sound,  might  have  been  better  than 
those  derived  from  extirpation.  It  is  not  the  direct 
result  of  the  operation  which  is  to  be  feared  in  a  case  of 
this  nature,  but  the  long  succeeding  confinement  in  bed. 
In  a  purulent  tubercular  condition  such  as  this  stripping 
of  the  vesicles  is  not  well  tolerated,  and  should  not  be 
attempted. 

CASE  XXXVII.  An  instance  of  defective  circulation 
and  of  general  debility  in  ■which  symptoms  existed  such  as 
are  often  associated  with  Chronic  Seminal  Vesiculitis.  No 
disease  of  the  seminal  vesicles.  In  a  case  such  as  this  all 
the  functions  are  weak,  therefore  weakness  of  the  sexual 
function  has  no  special  significance.  A  man,  aged  twenty- 
two  years,  frail  and  delicate,  and  had  been  so  all  his  life. 
Hands  and  face  were  blue.  There  was  a  cardiac  mur- 
mur which  had  the  indications  of  being  congenital. 
His  chest-expansion  was  very  defective.  He  could  not 
walk  up  stairs  or  at  all  fast  without  getting  out  of 
breath  and  feeling  faint.  His  digestion  was  weak.  He 
had  much  dyspepsia.  His  bowels  were  sluggish  and 
constipated.  His  mental  faculties  were  easily  tired  and 
were  lacking  in  force.  For  several  years  he  had  had 
frequent  emissions,  sometimes  occurring  by  day  and 
being  involuntary.  His  erections  were  very  feeble,  and 
his  sexual  desire  was  almost  nil.  Once  or  twice  in  his 
life  he  had  attempted  coitus,  but  at  such  times  he  had 
in  great  measure  failed,  through  want  of  sufficient  erec- 
tion and  through  a  premature  ejaculation.     Strange  as 


ILL  US  TEA  TIVE  INSTANCES.  235 

it  may  appear,  though  this  man  had  consulted  many 
doctors  before  calling  on  the  author,  the  opinion  he  had 
almost  invariably  received  was  that  his  sexual  weakness 
was  the  cause  of  his  general  debility,  and  if  that  could 
once  be  remedied  that  then  a  general  improvement  would 
speedily  occur.  Masturbation  had  been  ascribed  by 
most  of  the  authorities  consulted  as  the  original  cause 
for  the  sexual  weakness  in  this  case,  in  spite  of  the  fact 
that  the  patient  denied  ever  having  restarted  to  the 
practice  more  than  on  a  very  few  occasions.  The 
patient's  account  of  his  experiences  with  numerous 
doctors  in  regard  to  this  point  of  masturbation  was 
interesting.  Some  had  tried  to  bully  him  into  making 
an  open  confession ;  others  had  flatly  told  him  that  he 
was  a  masturbator,  that  they  did  not  care  whether  he 
denied  it  or  not,  as  the  evidences  of  it  were  apparent  in 
the  appearance  of  his  eyes,  in  his  expression,  etc. ;  while 
others  had  implored  him  to  make  a  confidant  of  them  in 
the  matter,  on  the  ground  that  the  confession  would 
never  go  further.  The  author's  opinion  was  that  the 
young  man  did  not  have  sufficient  energy  to  be  able  to 
abuse  himself  by  masturbation,  and  on  questioning  him 
he  admitted  that  whenever  he  had  attempted  masturba- 
tion or  coitus  the  feeling  of  exhaustion  afterward  had 
been  extreme.  Examination  of  the  seminal  vesicles 
showed  no  disease  in  those  organs.  The  patient  was 
told  that  his  sexual  organs  were  no  weaker  than  any  of 
his  other  organs.  He  was  advised  to  disregard  entirely 
his  sexual  symptoms,  and  to  leave  those  organs  alone. 
Hygienic  measures  were  prescribed,  especial  attention 
being  directed  to  chest-expansion  and  to  testing  and 
developing  the  latent  muscular  force  of  the  heart.  He 
was  advised  to  take  more  nourishment,  as  much  easily 
digested,  highly  nutritious  food  being  advised  as  it  was 


236  MALE  SEXUAL   ORGANS. 

possible  to  digest.  With  this  opinion  the  case  passed 
from  notice.  It  is  probable  that  a  case  of  this  descrip- 
tion could  be  made  comfortable  by  the  course  prescribed, 
but,  as  the  individual  in  question  had  always  been  pam- 
pered and  indulged,  it  is  doubtful  if  the  directions  were 
carried  out. 

CASE  XX  XVIII.  Hysteria,  simulating  in  many  "ways 
Chronic  Seminal  Vesiculitis.  A  man,  aged  thirty-five 
years,  strong  and  athletic,  had  had  gonorrhoea  three 
years  ago.  Since  that  time  he  had  read  and  consulted 
many  authorities  on  this  subject,  and  worried  much  lest 
his  trouble  might  remain  latent  and  incurable.  This 
last  idea  had  really  upset  his  mental  equilibrium  some- 
what. He  hinted  vaguely  that,  owing  to  some  trouble, 
he  could  never  in  all  probability  marry.  He  became 
moody  and  reclusive.  He  had  tales  of  accidents  that 
had  befallen  him  during  treatment  at  the  hands  of  the 
medical  advisers  whom  he  had  consulted.  One  »;entle- 
man  had  simply  searched  him  for  stricture,  and  as  a 
result  he  had  been  laid  up  in  bed  for  some  long  period 
in  such  pain  that  he  could  not  move.  The  painful 
symptoms,  however,  that  he  had  experienced  at  that 
time  as  the  result  of  cross-questioning  were  found  to 
be  vague  and  fantastic.  Another  adviser  was  sought, 
and  for  a  time  the  patient  stated  that  he  improved ;  but 
finally  that  surgeon,  as  the  result  of  some  endoscopic 
application,  so  injured  him,  in  his  estimation,  that  he 
had  to  go  to  bed  again  for  a  long  period.  The  next 
man  he  consulted,  after  hearing  his  story,  refused  to 
touch  his  urethra,  but  gave  him  an  alkali.  The  patient 
thought  that  after  a  time  the  alkali  had  thinned  his 
blood  and  made  him  anaemic.  He  therefore  had  no  g-ood 
word  to  say  for  this  surgeon.     Latterly  he  had  not  con- 


ILLUSTRATIVE  INSTANCES.  237 

suited  anyone  in  particular,  but  still  had  suffered  most 
of  the  time,  sometimes  from  sensations  in  the  perineum, 
at  others  from  urgent  urination  associated  with  pain. 
When  he  first  consulted  the  author  his  complaints  were 
as  follows  :  A  sore  feeling  in  the  rectum  after  defecation  : 
a  pain  above  the  pubes,  aggravated  by  straining  at  stool, 
by  erections,  or  by  much  exercise ;  a  stickiness  at  the 
meatus  after  erections ;  a  burning  sensation  at  the  end 
of  the  penis    and  a  feeling  of  vesical    tenesmus   after 
urinating.     He  was  easily  excited  in  a  sexual  way,  and 
after  such  occasions  all  his  painful  sensations  were  much 
intensified.    He  had  read  the  author's  article  on  seminal 
vesiculitis,  and  had  become  convinced  that  all  his  trouble 
lay  in  the  seminal  vesicles.     His  urine  was  clear  and 
normal,  with  the  exception  of  a  few  fine  filmy  shreds. 
Examination  of  the  vesicles  showed  nothing  abnormal, 
though  while  the  finger  was  being  introduced  into  the 
rectum  the  patient  became  quite  hysterical.    After  some 
days  he  returned  and  stated  that  he  thought  the  rectal 
exploration  had  done  him  good,  and  that  he  wished  it 
repeated.     This  was  accordingly  done.    The  next  day  a 
letter  was  received  stating  that  the  treatment  had  been 
too  severe ;  that  he  was  in  bed ;  could  not  move,  and 
was  fearful  that  he  would  be  laid  up  for  months  as  a 
result  of  the  treatment  to  which  he  had  just  been  sub- 
jected.    A  visit  was  accordingly  made  upon  him.     He 
had  no  temperature,  and  his  urine  was  clear.    By  divert- 
ing his  attention  it  was  seen  that  he  could  move  about 
and  make   motions,  which  on  previous  questioning  he 
had  stated  he  could  not  make.     The  author  accordingly 
gave  him  a  very  sharp  rebuke,  ordered  him  out  of  bed 
and  to  take  exercise.     He  was  told  that  his  troubles 
were  hysterical ;  that  they  befitted  a  woman  rather  than 
a  man ;  that  he  had  nothing  the  matter  with  him ;  that 


238  MALE  SEXUAL  ORGANS. 

he  should  stop  reading  medical  articles ;  that  he  should 
go  to  work  about  his  business  and  get  married.  The 
patient  was  not  seen  again  for  some  months,  at  the  end 
of  which  time  he  appeared  stating  that  he  felt  very 
grateful  for  the  advice  that  he  had  received.  He  had 
followed  the  course  laid  out  for  him.  He  then  realized 
that  his  symptoms  had  been  largely  the  result  of  a 
morbid  imagination.  He  felt  himself  well  and  was 
happy. 

A  much  longer  list  of  cases,  and  some  of  them  of 
interest,  could  have  been  given.  Still,  in  the  author's 
opinion,  a  study  of  those  herein  detailed  will  be  suffi- 
cient, together  with  an  acquaintance  with  the  earlier 
chapters,  to  enable  others  to  accomplish  much  in  the 
management  of  disease  of  the  seminal  vesicles. 


INDEX. 


A  BSCESS,  105,  131 

ii         pathological  investigation  of,  78 
Action  of  sexual  organs  and  heart  com- 
pared, 54 
Albarran,  63 
Albumin,  106,  213 
Alexander's  operation,  175 
Ampulla  of  Henle,  36,  40,  62,  163 

functions  of,  49 

histology  of,  40 
Anatomy,  17-48 
Appendicitis,  131 
Aspiration,  168 


BACILLI,  tubercular,  129 
Bacillary  infection,  187 
Bacillus  coli  commune,  90,  188 
Bacteria,  105,  138,  213 
Belfield,  75 
Bladder,  105,  107 

neck,  33 
Bleynie,  152 
Bottcher's  crystals,  52 
Biingner,  175 


i^ALCULUS,  67,  203,  227 

\J     Canals  of  seminal  vesicle,   37,  53, 

84 
Cancer,  66 

Caput  gallinaginis,  33 
Clinical  features,  80 
Coccyx,  141,  169,  171 
Coitus,  93,  156 
Cord,  62,  81,  83.  175,  181 
Cvstitis,  105,  131 
Cysts,  140 

echinococcus,  66,  75 


DIFFERENTIAL  diagnosis,  131 
Dissection,  18-40 
Drainage,  169 
Ducts  of  Miiller,  75 

ejaculatory,  28,  30,  50,  66 
atony  of,  152 


ECHINOCOCCUS  cysts,  66,75 
Ejaculation,  mechanism  of,  54,  95, 

148 
painful,  188,  205 
Ejaculatory  ducts  28,  30,  50,  66.  79,  83, 
105,  163 
atony  of,  152 

common  fibrous  sheath  of,  30 
histology  of,  46 
mouths  of,  33 
Emissions,  83,  93,  134, 185,  200,  203,  224, 

227 
Epididymitis,  acute,  131,  154 

tubercular,  128 
Epididymis,  61,  83,  1S4 
Ewing,  report  on  histology,  40-48,  51 
"Expression  test,"  163 
Extirpation  of  vesicles,  171 


FASCIA,  general  enveloping,  17,  19 
connecting    prostate    and    vesicles 

with  rectum,  20,  24,  28 
subperitoneal,  19 
Finger,  60,  73,  74 


pAY,  67 

U     Germs,  63,  105,  188 
Gonorrhoea,  78,  110,  114 
Gonorrhceal  rheumatism,  208 
Guelliot,  17,  36,  67,  74,  78 
Guyon,  61,  63,  110 


HALLE,  75,  76 
Heart,  action  of,  compared  to  that 
of  sexual  organs;  54 
Headache,  108,  224 
Hemorrhage,  200 
Henle,  ampulla  of,  36,  40,  62,  163 
functions  of,  49 
histology  of,  40 
Histories,  114 
Hydrocele.  140, 184 
Hysteria,  109,  136,  236 


240 


INDEX. 


TDIOTS,  136 

1     Illustrative  instances,  1S0-23S 
Impotency,  111,  134,  193,  219 
Incision  and  drainage,  169 
Inflammation,  perivesicular,  75,  78,  122 
acute,  pertaining  to  rectum,  131 
of  seminal  vesicles,  59 

gonorrhoeal,  60 

simple,  59 

tubercular,  60,  126,  166 
Inguinal  canal,  175 
Insomnia,  217 


KEYES,  67,  90,  101,  149,  150, 151,  227 
Kidney  pelvis,  63,  105 
colic,  131 
Kraske,  171,  176,  178 
Klotz,  164 
Krogius,  106 
Krotoszyner,  163 


T  ALLEMAND,  152 
Li     Lateral  lithotomy,  35,  40 
Lloyd,  16S,  169 

Lymph  space  between  rectum  and  pros- 
tate, 23 


ANIA,  136 

Masturbation,  95,  115,  136,  219 
involuntary,  190 
Mechanism  of  ejaculation,  54,  95 
Melancholia.  136,  188 
Mental  disturbances,  109,  184,  185,  200, 

215,218 
Morrow,  68,  69 
Muller,  ducts  of,  75 


ATECKER  school,  63 
1>     Nerve  disturbances,  64,  83, 110, 1 90, 
200,  218 


OPERATIVE  procedures,  165 
Otis,  104 


PAMPINIFORM  plexus,  19,  23,  39 
X      Paranoia,  136 
Pelvic  peritoneum,  20,  24 

peritonitis,  84,  132 
Penis,  96 
Perivesicular  inflammation,  75,  78,  122, 

126, 231 
Peschier,  67 
Phytolacca  decandra,  146 


Physical  signs  resulting  from  rectal  ex- 
ploration, 118,  132 
Pravaz's  syringe,  164 
Posner,  163 
Prostate,  anatomy  of,  18-40 

atrophy  of,  119 

hypertrophy  of,  119,  195 

infundibulum  of,  30,  34,  74 
Prostatitis,  acute,  131 

chronic,  139,  163 
Pus,  138,  147,  181,  182 
Pyaemia,  85 
Pyelitis,  107,  131 


RECTAL  exploration,  118,  132,  148 
Recto-vesical  space,  21 

perineal  cul-de-sac,  23 

puncture,  26 
Rectum,  140 
Reich,  147,  169 
Reymond,  64,  105 
Robin,  57,  70 
Roux,  174 
Rydygier,  176,  177,  178 


O  ARCOMA,  66 
lo  Schede,  177 
Scrotum,  96,  139 
Semen,  52,  68 

abnormal  coloring  of,  68 
amount  ejaculated,  57 
variations  in  consistency  of,  70 
Seminal  vesicle,  anatomy  of,  17-48 
calculus  of,  67,  203,  227 
canals  of,  37,  53 
extirpation  of,  170,  177 
fibrous  sheath  of,  20,  24 
functions  of,  49,  63 
histology  of,  40-48 
incision  and  drainage  of,  169 
inflammations  of,  59 
interior  of,  36 
muscular  trabecular  of,  39 
shape  of,  26,  34,  120 
stripping  of,  148 
walls  of,  72 
vesiculitis,  81 

acute,  direct  symptoms  of,  81 
caused    by    too    vigorous 

treatment,  54 
causes  for,  S5 

illustrative  cases,  180-183 
prognosis.  147 
treatment  of,  142 
tubercular,  127 
subacute,  direct  svmptoms,  88 
cases,  184,  230 


INDEX. 


241 


Seminal  vesiculitis,  subacute,  prognosis, 
165 
treatment,  148 
tubercular,  127 
chronic,  direct  symptoms,  88 
cases,  185-238 
hemorrhage  in,  154 
prognosis,  165 
treatment,  148 
tubercular,  127 
gonorrhceal,    direct    inflamma- 
tion, 60 
cases,  180 
tubercular,  126 

■cases,  183,  229,  231,  233 
treatment  of,  166 
functional  symptoms  of,  90 
physical   signs   resulting  from 
rectal  exploration,  87 
Senile  hypertrophy  of  prostate,  119 
Sexual  intercourse,  133 

weakness,  133,  193,  200,   205,  226, 

234 
function,  58,  63,  135 

effect  upon  it  of  pathological 
changes,  58 
Sick,  177 

Sinus  pocularis,  33 
Spermatic  colic,  94 
Spermatorrhoea,  149,  151 
Stricture.  134,  195 
Suicidal  tendency,  188 
Symptoms,  direct,  88 
indirect,  107 


TAYLOE,  161 
Testicle,  81,  96,  139,  143,  207 
atrophy  of,  65 
Testicular  secretion,  49 


Thorndike,  67 
Traumatisms,  66 
Treatment  and  prognosis.  142 
Trousseau,  151,  152 
Tubercular  disease,  60  126 
chronic,  128 
epididymitis,  128 


TTLLMANN,  173 
U  Ultzmann,  69 
Urethra,  97,  107 

prostatic,  32 
Urethritis,  posterior,  131,  139,  163,  180 
Urethral  discharges,  99,  100,  104,  121, 
127,  137,  182,  187,  191,  192,  197,  198, 
208,  211,  229 
Urethrotomy,  138 
Urine,  changes  in,  104,  127,  181 

retention  of,  193 
Urination,  81,  97,  132 

frequent,  180,  182,  192,  198,  213 


T7ARICOGELE,  65,  139,  218 
T       Vas  deferens,  20,  21,  30 

clubbed  end  of,  51,  55,  62,  65 
Verumontanum,  33 
Vesicular  fluid,  52 
Villeneuve,  175 
Von  Dittel,  147,  169,  173,  174,  177,  178 


w 


OLFF,  75 
Weir,  177 


7AHN,  67 
L     Zuckerkandl,    23, 
174,  177, 178 


170,    171,   173, 


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ATTFIELD  (JOHN).  CHEMISTRY ;  GENERAL,  MEDICAL  AND  PHAR- 
MACEUTICAL. Fourteenth  edition,  specially  revised  by  the  Author  for  America. 
In  one  handsome  12mo.  volume  of  794  pages,  with  88  illustrations.  Cloth,  §2.75; 
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BALL  (CHARLES  B.).  THE  RECTUM  AND  ANUS,  THEIR  DISEASES 
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60  engravings  and  4  colored  plates.  Cloth,  §2.25.  Just  ready.  See  Series  of  Clinical 
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BARNES  (ROBERT  AND  FANCOURT).  A  SYSTEM  OF  OBSTETRIC  MED- 
ICINE AND  SURGERY,  THEORETICAL  AND  CLINICAL.  The  Section  on 
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BARTHOLOW  ( ROBERTS ) .  CHOLERA  ;  ITS  CA  USATION,  PREVENTION 
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BERRY  ( GEORGE  A.).  DISEASES  OF  THE  EYE;  A  PRACTICAL  TREAT- 
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BLACK  (D.  CAMPBELL).  THE  URINE  IN  HEALTH  AND  DISEASE, 
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CALLY CONSIDERED.  In  one  12mo.  volume  of  256  pages,  with  73  engravings. 
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BLOXAM    (C.    L.).      CHEMISTRY,    INORGANIC    AND     ORGANIC.     With 

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volume  of  727  pages,  with  292  illustrations.     Cloth,  §2 ;  leather,  S3. 

BROADBENT  (W.  H.).  THE  PULSE.  In  one  12mo.  volume  of  317  pages,  with 
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BROWNE  ( LENNOX ) .  THE  THR OAT  AND  NOSE  AND  THEIR  DISEASES. 
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KOCH'S   REMEDY  IN  RELATION  ESPECIALLY   TO    THROAT 

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BRUCE    (J.    MITCHELL).     MATERIA    MEDIC  A    AND    THERAPEUTICS. 

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BRUNTON  (T.  LAUDER).  A  MANUAL  OF  PHARMACOLOGY,  THERA- 
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Action  and  the  Therapeutical  Uses  of  Drugs.     In  one  octavo  volume. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth  American 
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illustrations.     Cloth,  §6.50 ;  leather,  §7.50. 

BUMSTEAD  (F.  J.)  AND  TAYLOR  (R.  W.).  THE  PATHOLOGY  AND 
TREATMENT  OF  VENEREAL  DISEASES.  See  Taylor  on  Venereal  Diseases, 
page  15.     Just  ready. 

BURNETT   ( CHARLES  H.).     THE  EAR:  ITS  ANATOMY,  PHYSIOLOGY 

AND  DISEASES.     A  Practical  Treatise  for  the  Use  of  Students  and  Practitioners. 

Second  edition.     In  one  8vo.  volume  of  580  pages,  with  107  illustrations.     Cloth,  §4  ; 

leather,  §5. 
BUTLIN    (HENRY   T.).    DISEASES    OF   THE   TONGUE.    In  one  pocket-size 

12mo.  volume  of  456  pages,  with  8  colored  plates  and  3  engravings.     Limp  cloth,  §3.50. 

See  Series  of  Clinical  Manuals,  page  13. 

CARPENTER  (W.  B.).  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC 
LIQUORS  IN  HEALTH  AND  DISEASE,  ^'ew  edition,  with  a  Preface  by  D.  F. 
Condie,  M.D.     One  12mo.  volume  of  178  pages.     Cloth,  60  cents. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY.    In  one  large  octavo  volume.  • 


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CASPARI  (CHARLES,  JR.).  A  TREATISE  ON  PHARMACY.  For  Students 
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Just  ready.     Cloth,  §4.50. 

CHAMBERS  (T.  K.).    A  MANUAL  OF  DIET  IN  HEALTH  AND  DISEASE. 

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CHAPMAN  (HENRY  C).    A  TREATISE  ON  HUMAN  PHYSIOLOGY.    In 

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CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIOLOGICAL 
AND.  PATHOLOGICAL  CHEMISTRY.  In  one  handsome  octavo  volume  of  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  §3.50. 

CHEYNE  (W.  WATSON).  THE  TREATMENT  OF  WOUNDS,  ULCERS 
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CHURCHILL    (FLEETWOOD).     ESSAYS   ON  THE  PUERPERAL  FEVER. 

In  one  octavo  volume  of  464  pages.     Cloth,  §2.50. 

CLARKE  (W.  B.)  AND  LOCKWOOD  (C.  B.).     THE  DISSECTOR'S  MANUAL. 

In  one  12mo.  volume  of  396  pages,  with  49  engravings.     Cloth,  §1.50.     See  Students'  Series 
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CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF  THE 
HUMAN  BODY.     In  one  12mo.  volume  of  178  pages.     Cloth,  §1.25. 

CLINICAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  13. 

CLOUSTON  (THOMAS  S.).  CLINICAL  LECTURES  ON  MENTAL  DIS- 
EASES. With  an  Abstract  of  Laws  of  U.  S.  on  Custody  of  the  Insane,  by  C.  F.  Fol- 
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octavo  volume  of  108  pages.     Cloth,  §1.50. 

CLOWES    (FRANK).  AN  ELEMENTARY   TREATISE    ON  PRACTICAL 

CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALYSIS.    From  the 

fourth  English  edition.  In  one  handsome  12mo.  volume  of  387  pages,  with  55  engrav- 
ings.    Cloth,  §2.50. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  volume  of  829 
pages,  with  339  engravings.     Cloth,  §5.50 ;  leather,  §6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND  PATH- 
OL 0  G  Y.  With  Notes  and  Additions  to  adapt  it  to  American  Practice.  By  Thos.  C. 
Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one  handsome  octavo  volume  of  412  pages,  with 
331  engravings.     Cloth,  §3.25. 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DISEASES 
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719  pages.     Cloth,  §5.25 ;  leather,  §6.25. 

CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS  AND 
TREATMENT.  Translated,  with  Notes  and  Additions,  by  J.  Henry  C.  Simes,  M.D., 
and  J.  William  White,  M.D.  In  one  8vo.  volume  of  461  pages,  with  84  illustrations. 
Cloth,  §3.75. 

CULBRETH  (DAVID  M.  R.).    MATERIA  MEDICA  AND  PHARMACOLOGY. 

In  one  handsome  octavo  volume  of  812  pages,  with  445  engravings.     Cloth,  §4.75.     Just 
ready. 

CULVER  (E.  M.)  AND  HAYDEN  (J.  R.).  MANUAL  OF  VENEREAL  DIS- 
EASES.    In  one  12mo.  volume  of  289  pages,  with  33  engravings.     Cloth,  81.75. 

D ALTON  (JOHN  C.i.  A  TREATISE  ON  HUMAN  PHYSIOLOGY.  Seventh 
edition,  thoroughly  revised  and  greatly  improved.  In  one  very  handsome  octavo  volume 
of  722  pages,  with  252  engravings.     Cloth,  §5 ;  leather,  §6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.     In  one  hand- 


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DAVENPORT    (F.  H.).     DISEASES   OF   WOMEN.     A  Manual  of  Non-Surgical 

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DAVIS  (F.  H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second  edition.  In 
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DAVIS  (EDWARD  PJ.  A  TREATISE  ON  OBSTETRICS.  For  Students  and 
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DE  LA  BECHE'S  GEOLOGICAL  OBSERVER.  In  one  large  octavo  volume  of  700 
pages,  with  300  engravings.     Cloth,  §4. 

DENNIS  (FREDERIC  S.)  AND  BILLINGS  (JOHN  S.).  A  SYSTEM  OF 
S  UR  GER  Y.  In  Contributions  by  American  Authors.  In  four  very  handsome  octavo 
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DERCUM  (FRANCIS  X.),  Editor.  A  TEXT-BOOK  ON  NERVOUS  DIS- 
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341  engravings  and  7  colored  plates.     Cloth,  86;  leather,  87.     (Net.)     Just  ready. 

DE  SCHWEINITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS;  THEIR 
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DRAPER  i  JOHN  C. ) .  MEDICAL  PHYSICS.  A  Text-book  for  Students  and  Prac- 
titioners of  Medicine.  In  one  handsome  octavo  volume  of  734  pages,  with  376  engrav- 
ings.    Cloth,  84. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  A  new  American,  from  the  twelfth  London  edition,  edited  by  Stasteey 
Boyd,  F.B.C.S.  In  one  large  octavo  volume  of  965  pages,  with  373  engravings.  Cloth,  84 ; 
leather,  85. 

DUANE  (ALEXANDER).  THE  STUDENT'S  DICTIONARY  OF  MEDICINE 
AND  THE  ALLIED  SCIENCES.  Comprising  the  Pronunciation,  Derivation  and 
Full  Explanation  of  Medical  Terms.  Together  with  much  Collateral  Descriptive  Matter, 
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DUNCAN  'J.  MATTHEWS).  CLINICAL  LECTURES  ON  THE  DISEASES 
OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital.  In  one  octavo  volume  of 
175  pages.     Cloth,  81.50. 

DUNGLISON  ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCIENCE.  Con- 
taining a  full  Explanation  of  the  Various  Subjects  and  Terms  of  Anatomy,  Physiology, 
Medical  Chemistry,  Pharmacy,  Pharmacology,  Therapeutics,  Medicine,  Hygiene,  Dietetics, 
Pathology,  Surgery,  Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecology, 
Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc.  By  Bobley  DrxGLi- 
sox,  M.D.,  LL.D.,  late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  Col- 
lege of  Philadelphia.  Edited  by  Bichakd  J.  Duxglisox,  A.M.,  M.D.  Twenty-first 
edition,  thoroughly  revised  and  greatly  enlarged  and  improved,  with  the  Pronunciation, 
Accentuation  and  Derivation  of  the  Terms.  "With  Appendix.  Just  ready.  In  one 
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EDES  (ROBERT  T.\  TEXT-BOOK  OF  THERAPEUTICS  AND  MATERIA 
MEDIC  A.     In  one  8vo.  volume  of  544  pages.     Cloth,  83.50 ;  leather,  84.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for  Students  and 
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Cloth,  S3 ;  leather,  84. 

ELLIS  (GEORGE  VINER>.  DEMONSTRATIONS  IN  ANATOMY.  Being  a 
Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection.  From  the  eighth  and  revised 
English  edition.  In  one  octavo  volume  of  716  pages,  with  249  engravings.  Cloth,  84.25 ; 
leather,  85.25. 

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C  YNJECOL  OGY.  For  the  use  of  Students  and  Practitioners.  Third  edition,  enlarged 
and  revised.  In  one  large  8vo.  volume  of  880  pages,  with  150  original  engravings. 
Cloth,  $5  ;  leather,  $6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SURGERY.  A  new 
American  from  the  eighth  enlarged  and  revised  London  edition.  In  two  large  octavo 
volumes  containing  2316  pages,  with  984  engravings.     Cloth,  $9 ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  See  American  Text-books 
of  Dentistry,  page  2. 

FARQUH ARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS.  Fourth 
American  from  fourth  English  edition,  revised  by  Frank  Woodbury,  M.D.  In  one 
12mo.  volume  of  581  pages.     Cloth,  $2.50. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE  EAR.  Fourth 
edition.  In  one  octavo  volume  of  391  pages,  with  73  engravings  and  21  colored  plates. 
Cloth,  $3.75. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  MEDICINE.  New  (7th)  edition,  thoroughly  revised  by  Frederick  P.  Henry, 
M.D.     In  one  large  8vo.  volume  of  1143  pages,  with  engravings.     Cloth,  $5 ;  leather,  $6. 

A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION ;  of  the  Physi- 


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edition,  revised  by  James  C.  Wilson,  M.D.  In  one  handsome  12mo.  volume  of  274 
pages,  with  12  engravings. 

A   PRACTICAL    TREATISE   ON   THE  DIAGNOSIS  AND    TREAT- 


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octavo  volume  of  550  pages.     Cloth,  $4. 

A   PRACTICAL   TREATISE  ON  THE  PHYSICAL  EXPLORATION 


OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES  AFFECTING 
THE  RESPIRATOR  Y  ORGANS.  Second  and  revised  edition.  In  one  octavo  vol- 
ume of  591  pages.     Cloth,  $4.50. 

MEDICAL  ESSAYS.    In  one  12mo.  volume  of  210  pages.     Cloth,  $1.38. 

ON  PHTHISIS :  ITS  MORBID  ANA TOMY,  ETIOL OGY,  ETC.    A  Series 


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FOLSOM  (C.  F.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S.  ON  CUSTODY 
OF  THE  INSANE.     In  one  8vo.  volume  of  108  pages.     Cloth,  $1.50. 

FORMULARY,  THE  NATIONAL.  See  Stille,  Maisch  &  Caspari's  National  Dispensa- 
tory, page  14. 

FOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  New  (6th)  and 
revised  American  from  the  sixth  English  edition.  In  one  large  octavo  volume  of  923 
pages,  with  257  illustrations.     Cloth,  $4.50 ;  leather,  $5.50. 

FOTHERGILL  (J.  MILNER).  THE  PRACTITIONER'S  HAND-BOOK  OF 
TREATMENT.  Third  edition.  In  one  handsome  octavo  volume  of  664  pages. 
Cloth,  $3.75  ;  leather,  $4.75. 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEMISTRY  (IN- 
ORGANIC AND  ORGANIC).  Twelfth  edition.  Embodying  Watts'  Physical  and 
Inorganic  Chemistry.  In  one  royal  12mo.  volume  of  1061  pages,  with  168  engravings,  and 
1  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 

FRANKLAND  (E.)  AND  JAPP  (F.  R\).  INORGANIC  CHEMISTRY.  In  one 
handsome  octavo  volume  of  677  pages,  with  51  engravings  and  2  plates.  Cloth,  $3.75  ; 
leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  ORGANS  IN  THE 
MALE.  In  one  very  handsome  octavo  volume  of  238  pages,  with  25  engravings  and 
8  full-page  plates.     Cloth,  $2.     Just  ready. 

FULLER  (HENRY) .  ON  DISEASES  OF  THE  L  UNGS  AND  AIR-PASS  A  GES. 
Their  Pathology,  Physical  Diagnosis,  Symptoms  and  Treatment.  From  second  English 
edition.     In  one  8vo.  volume  of  475  pages.     Cloth,  $3.50. 


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GANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  AMultumin 
Parvo.     In  one  square  octavo  volume  of  845  pages,  with  159  engravings.     Cloth,  $3.75. 

GIBBES  (HENEAGE).  PRACTICAL  PATHOLOGY  AND  MORBID  HIS- 
TOLOGY. In  one  very  handsome  octavo  volume  of  314  pages,  with  60  illustrations, 
mostly  photographic.     Cloth,  $2.75. 

GIBNEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practitioners  and 
Students.     In  one  8vo.  volume  profusely  illustrated.     Preparing. 

GOULD  (A.  PEARCE).     SURGICAL  DIAGNOSIS.    In  one  12mo.  volume  of  589 

pages.     Cloth,  §2.     See  Students'  Series  of  Manuals,  page  14. 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL.  A  new 
American  edition,  thoroughly  revised.  In  one  imperial  octavo  volume  of  1200  pages, 
with  nearly  800  large  and  elaborate  engravings.  Price  with  illustrations  in  colors,  cloth, 
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DISEASES.  For  Students  and  Practitioners  of  Medicine.  New  (2d)  edition.  In  one 
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GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND  MOR- 
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GREENE  (WILLIAM  H.).    A  MANUAL  OF  MEDICAL  CHEMISTRY.    For 

the  Use  of  Students.     Based  upon  Bowman's  Medical  Chemistry.     In  one  12mo.  volume 
of  310  pages,  with  74  illustrations.     Cloth,  $1.75. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DISEASES, 
INJURIES  AND  MALFORMATIONS  OF  THE  URINARY  BLADDER, 
THE  PROSTATE  GLAND  AND  THE  URETHRA.  Third  edition,  thoroughly 
revised  and  edited  bv  Samitee  W.  Gross,  M.  D.  In  one  octavo  volume  of  574  pages, 
with  170  illustrations'     Cloth,  §4.50. 

HABERSHON  (S.  0.).  ON  THE  DISEASES  OF  THE  ABDOMEN,  comprising 
those  of  the  Stomach,  (Esophagus,  Caecum,  Intestines  and  Peritoneum.  Second  Amer- 
ican from  the  third  English  edition.  In  one  octavo  volume  of  554  pages,  with  11  engrav- 
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HAMILTON  (ALLAN  McLANE) .  NER  VO  US  DISEASES,  THEIR  DESCRIP- 
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598  pages,  with  72  engravings.     Cloth,  $4. 

HAMILTON  (FRANK  H.).  A  PRACTICAL  TREATISE  ON  FRACTURES 
AND  DISLOCATIONS.  Eighth  edition,  revised  and  edited  by  Stephen  Smith, 
A.M.,  M.D.  In  one  handsome  octavo  volume  of  832  pages,  with  507  engravings. 
Cloth,  §5.50;  leather,  §6.50. 

HARD  AW  AY  i  W.  A.).  MANUAL  OF  SKIN  DISEASES.  In  one  12mo.  volume 
of  440  pages.     Cloth,  §3. 

HARE  (HOBART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL  THERA- 
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and  their  Employment  upon  a  Rational  Basis.  With  articles  on  various  subjects  by  well- 
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eminent  Physicians.  Three  large  octavo  volumes  comprising  3544  pages,  with  434 
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PRACTICE    OF   MEDICINE.     Fifth  edition.     In  one  12mo.  volume,  669   pages, 
with  144  engravings.     Cloth,  §2. 75 ;  half  bound,  §3. 

A   HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.    In  one  12mo. 

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A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.    Comprising  Manuals 


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HAYEM  (GEORGES)  AND  HARE  (H.  A.).  PHYSICAL  AND  NATURAL 
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HERMAN    (G.    ERNEST).    FIRST  LINES  IN  MIDWIFERY.     In  one  12mo. 

volume  of  198  pages,  with  80  engravings.  Cloth,  $1.25.  See  Students'  Series  of  Manuals, 
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Meade  Smith,  M.D.     In  one  12mo.  vol.  of  199  pages,  with  32  engravings.     Cloth,  $1.50. 

HERRICK  (JAMES  B.).  A  HANDEOOK  OF  DIAGNOSIS.  In  one  handsome 
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HILLIER  (THOMAS).  A  HANDEOOK  OF  SKIN  DISEASES.  Second  edition. 
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HIRST  (BARTON  C.)  AND  PIERSOL  (GEORGE  A.).  HUMAN  MONSTROS- 
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ings and  39  large  photographic  plates  from  nature.  In  four  parts,  price  each,  $5.  Limited 
edition.     For  sale  by  subscription  only. 

HOBLYN  (RICHARD  D.).  A  DICTIONARY  OF  THE  TERMS  USED  IN 
MEDICINE  AND  THE  COLLATERAL  SCIENCES.  In  one  12mo.  volume  of 
520  doubled-columned  pages.     Cloth,  $1.50;  leather,  $2. 

HODGE  (HUGH  L.).  ON  DISEASES  PECULIAR  TO  WOMEN,  INCLUDING 
DISPLACEMENTS  OF  THE  UTERUS.  Second  and  revised  edition.  In  one 
8vo.  volume  of  519  pages,  with  illustrations.     Cloth,  $4.50. 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.).    A  MANUAL 

OF  CHEMICAL  ANAL  YSIS,  as  Applied  to  the  Examination  of  Medicinal  Chemicals 
and  their  Preparations.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one 
handsome  octavo  volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLDEN  (LUTHER).  LANDMARKS,  MEDICAL  AND  SURGICAL.  From 
the  third  English  edition.  With  additions  by  W.  W.  Keen,  M.D.  In  one  royal  12mo. 
volume  of  148  pages.     Cloth,  $1. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Principles  and 
Practice.  A  new  American  from  the  fifth  English  edition.  Edited  by  T.  Pickering 
Pick,  F.R.C.S.  In  one  handsome  octavo  volume  of  1008  pages,  with  428  engravings. 
Cloth,  $6 ;  leather,  $7. 

A  SYSTEM  OF  SURGERY.     With  notes  and  additions  by  various  American 


authors.  Edited  by  John  H.  Packard,  M.  D.  In  three  very  handsome  8vo.  volumes 
containing  3137  double-columned  pages,  with  979  engravings  and  13  lithographic  plates. 
Per  volume,  cloth,  $6  ;  leather,  $7  ;  half  Russia,  $7.50.     For  sale  by  subscription  only. 

HORNER  (WILLIAM  E.).  SPECIAL  ANATOMY  AND  HISTOLOGY.  Eighth 
edition,  revised  and  modified.  In  two  large  8vo.  volumes  of  1007  pages,  containing  320 
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HUDSON  (A.).  LECTURES  ON  THE  STUDY  OF  FEVER.  In  one  octavo 
volume  of  308  pages.     Cloth,  82.50. 

HUTCHINSON  (JONATHAN).  SYPHILIS.  In  one  pocket-size  12mo.  volume  of 
542  pages,  with  8  chromo-lithographic  plates.  Cloth,  S2. 25.  See  Series  of  Clinical  Man- 
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HYDE  (JAMES  NEVINS).  A  PRACTICAL  TREATISE  ON  DISEASES  OF 
THE  SKIN.  Third  edition,  thoroughly  revised.  In  one  octavo  volume  of  802  pages, 
with  108  engravings  and  9  colored  plates.     Cloth,  So  ;  leather,  $6. 

JACKSON  (GEORGE  THOMAS ) .  THE  READ  Y-REFERENCE  HANDB  0  OK 
OF  DISEASES  OF  THE  SKIN.  New  (2d)  edition.  In  one  12mo.  volume  of  589 
pages,  with  69  engravings,  and  one  colored  plate.     Cloth,  82. 75.     Just  re 


JAMIESON  (W.  ALLAN).  DISEASES  OF  THE  SKIN.  Third  edition.  In  one 
octavo  volume  of  656  pages,  with  1  engraving  and  9  double-page  chromo-lithographic 
plates.     Cloth,  86. 

JONES  (C.  HANDFIELD).     CLINICAL  OBSERVATIONS  ON  FUNCTIONAL 

NERVOUS  DISORDERS.    Second  American  edition.     In  one  octavo  volume  of  340 
pages.     Cloth,  83.25. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE  AND 
PRACTICE.  Second  edition.  In  one  octavo  volume  of  549  pages,  with  201  engrav- 
ings, 17  chromo-lithographic  plates,  test-types  of  Jaeger  and  Snellen,  and  Holmgren's 
Color-Blindness  Test.     Cloth,  So.  50 ;  leather,  86. 50. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  See  American  Text-books  of 
Dentistry,  page  2. 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Sixth  edition.  In  one  12mo. 
volume  of  532  pages,  with  221  illustrations.     Cloth,  82.50. 

KLEIN  (E.).  ELEMENTS  OF  HISTOLOGY.  Fourth  edition.  In  one  pocket-size 
12mo.  volume  of  376  pages,  with  194  engravings.  Cloth,  81-75.  See  Students'  Series  of 
Manuals,  page  14. 

LANDIS  (HENRY  G.).  THE  MANAGEMENT  OF  LABOR.  In  one  handsome 
12mo.  volume  of  329  pages,  with  28  illustrations.     Cloth,  81-75. 

LA  ROCHE  (R.).  YELLOW  FEVER.  In  two  8vo.  volumes  of  1468  pages. 
Cloth,  87. 

PNEUMONIA.    In  one  8vo.  volume  of  490  pages.     Cloth,  83. 

LAURENCE  (J.  Z.)  AND  MOON  (ROBERT  C).  A  HANDY-BOOK  OF 
OPHTHALMIC  SURGERY.  Second  edition.  In  one  octavo  volume  of  227  pages, 
with  66  engravings.     Cloth,  82.75. 

LAWSON  (GEORGE).    INJURIES  OF  THE  EYE,  ORBIT  AND  EYELIDS. 

From  the  last  English  edition.     In  one  handsome  octavo  volume  of  404  pages,  with  92 
engravings.     Cloth,  83.50. 

LEA  (HENRY  C).  CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF 
SPAIN;  CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINATI ; 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  DE  LA  GUARDIA ;  BRI- 
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A  HISTORY  OF  AURICULAR  CONFESSION  AND  INDULGENCES 

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Per  volume,  cloth,  83.      Complete  vjorkjust  ready. 

FORMULARY  OF  THE  PAPAL  PENITENTIARY.  In  one  octavo  vol- 
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SUPERSTITION  AND  FORCE;  ESSAYS  ON  THE  WAGER  OF  LAW, 


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LEA  (HENRY  C).  STUDIES  IN  CHURCH  HISTORY.  The  Rise  of  the  Tem- 
poral Power — Benefit  of  Clergy — Excommunication.  New  edition.  In  one  handsome 
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AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY  IN  THE 


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pages.     Cloth,  $4.50. 

LEE  (HENRY)   ON  SYPHILIS.     In  one  8vo.  volume  of  246  pages.     Cloth,  $2.25. 

LEHMANN   (C.  G.).     A  MANUAL  OF  CHEMICAL  PHYSIOLOGY.     In  one 

8vo.  volume  of  327  pages,  with  41  engravings.     Cloth,  $2.25. 

LEISHMAN  (WILLIAM).  A  SYSTEM  OF  MIDWIFERY.  Including  the  Dis- 
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LOOMIS  (ALFRED  L.)  AND  THOMPSON  (W.  GILMAN),  Editors.  A  SYS- 
TEM OF  MEDICINE.  In  Contributions  by  Various  American  Authors.  In  four 
very  handsome  octavo  volumes  of  about  900  pages  each,  fully  illustrated  in  black  and 
colors.     Volume  I.,  in  press  for  early  issue. 

LUDLOW  (J.  L.l.  A  MANUAL  OF  EXAMINATIONS  UPON  ANATOMY, 
PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE,  OBSTETRICS, 
MATERIA  MEDIC  A,  CHEMISTRY,  PHARMACY  AND  THERAPEUTICS. 
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of  816  pages,  with  370  engravings.     Cloth,  $3.25;  leather,  $3.75. 

LUFF  (ARTHUR  P.).  MANUAL  OF  CHEMISTRY,  for  the  use  of  Students  of 
Medicine.  In  one  12mo.  volume  of  522  pages,  with  36  engravings.  Cloth,  $2.  See 
Students'  Series  of  Manuals,  page  14. 

LYMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDICINE.  In  one  very  hand- 
some octavo  volume  of  925  pages  with  170  engravings.     Cloth,  $4. 75 ;  leather,  $5. 75. 

LYONS  (ROBERT  D.).     A  TREATISE  ON  FEVER.     In  one  octavo  volume  of  362 

pages.     Cloth,  §2.25. 

MACKENZIE  (JOHN  NOLAND).  THE  DISEASES  OF  THE  NOSE  AND 
THROAT.  In  one  handsome  octavo  volume  of  about  600  pages,  richly  illustrated. 
Preparing. 

MAISCH    (JOHN  M.).    A   MANUAL    OF   ORGANIC  MATERIA   MEDIC  A. 

New  (6th)  edition,  thoroughly  revised  by  H.  C.  C.  Maisch,  Ph.G-.,  Ph.D.     In  one  very 
handsome  12mo.  volume  of  509  pages,  with  285  engravings.     Cloth,  $3. 

MANUALS.  See  Students'  Quiz  Series,  page  14,  Students'  Series  of  Manuals,  page  14,  and 
Series  of  Clinical  Manuals,  page  13. 

MARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  In  one  12mo.  volume  of 
468  pages,  with  64  engravings  and  a  colored  plate.  Cloth,  $2.  See  /Series  of  Clinical 
Manuals,  page  13. 

MAY   (C.  H.)    MANUAL  OF  THE  DISEASES  OF  WOMEN.     For  the  use  of 

Students  and  Practitioners.     Second  edition,  revised  by  L.  S.  Rait,  M.D.     In  one  12mo. 
volume  of  360  pages,  with  31  engravings.     Cloth,  $1.75. 

MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  INJURIES  OF 
NERVES  AND  THEIR  TREATMENT.  In  one  handsome  12mo.  volume  of  239 
pages,  with  12  illustrations.     Cloth  $1.75.     Just  ready. 

MORRIS    (HENRY).    SURGICAL    DISEASES   OF   THE   KIDNEY.     In  one 

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MORRIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  In  one  square  8vo.  volume 
of  572  pages,  with  19  chromo-lithographic  figures  and  17  engravings.     Cloth,  S3. 50. 

MULLER  (J.).    PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.     In  one 

large  8vo.  volume  of  623  pages,  with  538  engravings.     Cloth,  84.50. 

MUSSER  (JOHN  H.).  A  PRACTICAL  TREATISE  ON  MEDICAL  DIAG- 
NOSIS, for  Students  and  Physicians.  Xew  (2d)  edition-  In  one  octavo  volume  of 
about  950  pages,  illustrated  with  about  200  engravings  and  many  colored  plates.    In  press. 

NATIONAL  DISPENSATORY.     See  Stille,  Maiseh  &  Caspari,  page  14. 

NATIONAL  FORMULARY.  See  Stille,  Maiseh  &  Caspari's  National  Dispensatory, 
page  14. 

NATIONAL  MEDICAL  DICTIONARY.     See  Billings,  page  3. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.  Fourth  American  from  fifth 
English  edition.  In  one  12mo.  volume  of  504  pages,  with  164  engravings,  test-types  and 
formulae  and  color-blindness  test.     Cloth,  S2. 

NORRIS  (WM.  F.)  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF  OPHTHAL- 
MOLOGY. In  one  octavo  volume  of  641  pages,  with  357  engravings  and  5  colored 
plates.     Cloth,  85 ;  leather,  86. 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN.  In  one  12mo. 
volume  of  525  pages,  with  85  engravings  and  4  colored  plates.  Cloth,  82.  See  Series  of 
Clinical  Manuals,  page  13. 

PARK  (ROSWELL),  Editor.  A  TREATISE  ON  SURGERY,  by  American  Authors. 
For  Students  and  Practitioners  of  Surgery  and  Medicine.  In  two  magnificent  octavo 
volumes,  containing  1600  pages,  with  about  850  engravings,  and  about  40  full  page  plates 
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Price  per  volume,  cloth,  84. 50 ;  leather,  85. 50.     Net. 

PARRY  (JOHN  S.).  EXTRA-UTERINE  PREGNANCY,  ITS  CLINICAL 
HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREATMENT.  In  one  octavo 
volume  of  272  pages.     Cloth,  82.50. 

PARVIN   fTHEOPHILUS).     THE  SCIENCE  AND  ART  OF  OBSTETRICS. 

Third  edition      In  one  handsome  octavo  volume  of  677  pages,  with  267  engravings  and 
2  colored  plates.     Cloth,  84.25;  leather,  85  25. 

PAVY  (F.  W.)  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION,  ITS 
DISORDERS  AND  THEIR  TREATMENT.  From  the  second  London  edition. 
In  one  8vo.  volume  of  238  pages-     Cloth,  $2. 

PAYNE    (JOSEPH   FRANK).    A   MANUAL   OF  GENERAL  PATHOLOGY 

Designed  as  an  Introduction  to  the  Practice  of  Medicine.     In  one  octavo  volume  of  524 
pages,  with  153  engravings  and  1  colored  plate      Cloth,  83.50. 

PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  2. 

PEPPER  (A.  J.).  SURGICAL  PATHOLOGY.  In  one  12mo  volume  of  511  pages, 
with  81  engravings.     Cloth,  82.     See  Students'  Series  of  Manuals,  page  14. 

PICK  (T.  PICKERING).  FRACTURES  AND  DISLOCATIONS.  In  one  12mo. 
volume  of  530  pages,  with  93  engravings.    Cloth,  82.    See  Series  of  Clinical  Manuals,  p.  13. 

PIRRIE  (WILLIAM) .     THE  PRINCIPLES  AND  PRA CTICE  OF  SURGER Y. 

In  one  octavo  volume  of  780  pages,  with  316  engravings.     Cloth,  83-75. 

PL  A  YF  AIR  (W.  SA  A  TREATISE  ON  THE  SCIENCE  AND  PRACTICE 
OF  MID  WIFER  Y.  Sixth  American  from  the  eighth  English  edition.  Edited,  with 
additions,  by  R.  P.  Harris,  M.D.  In  one  octavo  volume  of  697  pages,  with  217  engrav- 
ings and  5  plates.     Cloth,  84 ;  leather,  85.  QQ 

THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRATION  AND 


HYSTERIA.     In  one  12mo.  volume  of  97  pages.     Cloth,  81. 


Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Ave.  {cor.  18th  St.). 


12  LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 

POLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE  EAR 
AND  ADJACENT  ORGANS.  Second  American  from  the  third  German  edition. 
Translated  by  Oscar  Dodd,  M.D ,  and  edited  by  Sir  William  Dalby,  F.E.C.S.  In 
one  octavo  volume  of  748  pages,  with  330  original  engravings.     Cloth,  §5.50. 

POWER  (HENRY).  HUMAN  PHYSIOLOGY.  Second  edition.  In  one  12mo. 
volume  of  396  pages,  with  47  engravings.  Cloth,  §1.50.  See  Student?  s  Series  of  Manuals, 
page  14. 

PURDY  (CHARLES  W.).  BRIGHT'S  DISEASE  AND  ALLIED  AFFEC- 
TIONS OF  THE  KIDNEY.  In  one  octavo  volume  of  288  pages,  with  18  engrav- 
ings.    Cloth,  §2. 

PYE-SMITH  (PHILIP  H.).  DISEASES  OF  THE  SKIN.  In  one  12mo.  volume 
of  407  pages,  with  28  illustrations,  18  of  which  are  colored.     Cloth,  §2. 

QUIZ  SERIES.     See  Students'  Quiz  Series,  page  14. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one  12mo.  volume  of 
of  314  pages,  with  16  engravings.     Cloth,  §1.50.     See  Students'  Series  of  Manuals,  page  14. 

RAMSBOTHAM  (FRANCIS  H.).  THE  PRINCIPLES  AND  PRACTICE  OF 
OBSTETRIC  MEDICINE  AND  SURGERY.  In  one  imperial  octavo  volume  of 
640  pages,  with  64  plates  and  numerous  engravings  in  the  test.  Strongly  bound  in 
leather,  §7. 

REICHERT    (EDWARD    T.).     A    TEXT-BOOK   ON  PHYSIOLOGY.     In  one 

handsome  octavo  volume  of  about  800  pages,  richly  illustrated.     Preparing. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEMISTRY. 
Fourth  edition,  thoroughly  revised  and  much  enlarged.  In  one  12mo.  volume  of  325 
pages.     Cloth,  §2. 

REYNOLDS  (J.  RUSSELL).  A  SYSTEM  OF  MEDICINE.  Edited,  with  notes 
and  additions,  by  Henry  Hartshorne,  M.D.  In  three  large  8vo.  volumes,  containing 
3056  closely  printed  double-columned  pages,  with  317  engravings.  Per  volume,  cloth,  §5 ; 
leather,  §6. 

RICHARDSON   (BENJAMIN  WARD).    PREVENTIVE  MEDICINE.    In  one 

octavo  volume  of  729  pages.     Cloth,  §4 ;  leather,  §5. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  In  one  octavo  volume  of  780  pages,  with  501  engravings.  Cloth,  §4.50; 
leather,  §5.50. 

THE  COMPEND  OF  ANATOMY.     For  use  in  the  Dissecting  Room  and  in 

preparing  for  Examinations.     In  one  16mo.  volume  of  196  pages.     Limp  cloth,  75  cents. 

ROBERTS  (SIR  WILLIAM).  A  PRACTICAL  TREATISE  ON  URINARY 
AND  RENAL  DISEASES,  INCLUDING  URINARY  DEPOSITS.  Fourth 
American  from  the  fourth  London  edition.  In  one  very  handsome  8vo.  volume  of  609 
pages,  with  81  illustrations.     Cloth,  §3.50. 

ROBERTSON  (J.  McGREGOR).  PHYSIOLOGICAL  PHYSICS.  In  one  12mo. 
volume  of  537  pages,  with  219  engravings.  Cloth,  §2.  See  Students'  Series  of  Manuals, 
page  14. 

ROSS  (JAMES).  A  HANDBOOK  OF  THE  DISEASES  OF  THE  NERVOUS 
SYSTEM.  In  one  handsome  octavo  volume  of  726  pages,  with  184  engravings.  Cloth, 
§4. 50 ;  leather,  §5. 50. 

SAVAGE  (GEORGE  H.).  INSANITY  AND  ALLIED  NEUROSES,  PRACTI- 
CAL AND  CLINICAL.  In  one  12mo.  volume  of  551  pages,  with  18  typical  engrav- 
ings.    Cloth,  §2.     See  Series  of  Clinical  Manuals,  page  13. 

SCHAFER  (EDWARD  A. ) .  THE  ESSENTIALS  OF  HISTOL  OGY,  DESCRIP- 
TIVE AND  PRACTICAL.  For  the  use  of  Students.  New  (4th)  edition.  In  one 
handsome  octavo  volume  of  311  pages,  with  288  illustrations.     Cloth,  §3. 


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LEA    BROTHERS    &     CO.'S    PUBLICATIONS.  13 

SCHMITZ  AND  ZUMPT'S  CLASSICAL  SERIES. 

ADVANCED  LATIN  EXERCISES     Cloth,  60  cents;  half  bound,  70  cents. 
SCHMITZ' S  ELEMENTARY  LATIN  EXERCISES.     Cloth,  50  cents. 
SALLUST.     Cloth,  60  cents ;  half  bound,  70  cents. 
NEPOS.     Cloth,  60  cents ;  half  bound,  70  cents. 
VIRGIL.     Cloth,  85  cents;  half  bound,  $1. 
CURTIUS.     Cloth,  80  cents;  half  bound,  90  cents. 

SCHOFIELD  (ALFRED  T.).  ELEMENTARY  PHYSIOLOGY  FOR  STU- 
DENTS. In  one  12mo.  volume  of  380  pages,  with  227  engravings  and  2  colored  plates. 
Cloth,  §2. 

SCHREIBER  (JOSEPH).  A  MANUAL  OF  TREATMENT  BY  MASSAGE 
AND  METHODICAL  MUSCLE  EXERCISE.  Translated  by  Walter  Mendel- 
son,  M.D.,  of  New  York.  In  one  handsome  octavo  volume  of  274  pages,  with  117  fine 
engravings. 

SEILER  (CARL\  A  HANDBOOK  OF  DIAGNOSIS  AND  TREATMENT  OF 
DISEASES  OF  THE  THROAT  AND  NASAL  CAVITIES.  Fourth  edition. 
In  one  12mo.  vol.  of  414  pages,  with  107  engravings,  and  2  colored  plates.     Cloth,  $2.25. 

SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edition.  In  one 
octavo  volume  of  268  pages,  with  13  plates,  10  of  which  are  colored,  and  9  engravings. 
Cloth,  §2. 

SERIES  OF  CLINICAL  MANUALS.  A  Series  of  Authoritative  Monographs  on 
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$2.25;  Hutchinson  on  Syphilis,  $2.25;  Marsh  on  Diseases  of  the  Joints,  $2;  Morris 
on  Surgical  Diseases  of  the  Kidney,  $2.25;  Owen  on  Surgical  Diseases  of  Children,  $2; 
Pick  on  Fractures  and  Dislocations,  $2;  Butlin  on  the  Tongue,  $350;  Savage  on 
Insanity  and  Allied  Neuroses,  $2 ;  and  Treves  on  Intestinal  Obstruction,  $2. 
For  separate  notices,  see  under  various  authors'  names. 

SERIES  OF  STUDENTS'  MANUALS.    See  next  page. 

SIMON  (CHARLES  E.)  CLINICAL  DIAGNOSIS,  BY  MICROSCOPICAL 
AND  CHEMICAL  METHODS.  In  one  handsome  octavo  volume  of  504  pages,  with 
132  engravings',  and  10  full  page  plates  in  colors  and  monochrome.  Cloth,  $3.50.  Just 
ready. 

SIMON  (W.).t  MANUAL  OF  CHEMISTRY.  A  Guide  to  Lectures  and  Laboratory 
Work  for  Beginners  in  Chemistry.  A  Text-book  specially  adapted  for  Students  of  Phar- 
macy and  Medicine.  Fifth  edition  In  one  8vo.  volume  of  501  pages,  with  44  engrav- 
ings and  8  plates  showing  colors  of  64  tests.     Cloth,  $3.25- 

SLADE  (D.  D.).  DIPHTHERIA  ;  ITS  NATURE  AND  TREATMENT.  Second 
edition.     In  one  royal  12mo.  volume,  158  pages.     Cloth,  $1.25. 

SMITH  (EDWARD).     CONSUMPTION ;   ITS  EARLY  AND  REMEDIABLE 

STAGES.     In  one  8vo.  volume  of  253  pages.     Cloth,  $2.25. 

SMITH    (J.   LEWIS).     A    TREATISE   ON  THE  DISEASES   OF  INFANCY 
rAND    CHILDHOOD.      New    (8th)    edition,  thoroughly  revised   and  rewritten   and 
greatly  enlarged.     In  one  large  8vo.  volume  of  983  pages,  with  273  illustrations  and 
4  full-page  plates.     Cloth,  $1.50  ;  leather,  $5.50.     Just  ready . 

SMITH  (STEPHEN).  OPERATIVE  SURGERY.  Second  and  thoroughly  revised 
edition.     In  one  octavo  vol.  of  892  pages,  with  1005  engravings.     Cloth,  $4 ;  leather,  $5. 

SOLLY    (S.    EDWIN).     A    HANDBOOK    OF   MEDICAL    CLIMATOLOGY. 

Handsome  octavo.     Preparing. 

STILLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUSATION, 
SYMPTOMS,  LESIONS,  PREVENTION  AND  TREATMENT.  In  one  12mo. 
volume  of  163  pages,  with  a  chart  showing  routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS  AND  MATERIA  MEDIC  A.     Fourth  and  revised  edition. 


In  two  octavo  volumes,  containing  1936  pages.     Cloth,  $10;  leather,  $12. 


Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Ave.  (cor.  18th  St.). 


14  LEA    BROTHERS    &     CO.'  S    PUBLICATIONS. 

STILLE    'ALFRED),   MAISCH   (JOHN   M.)   AND   CASPARI   (CHAS.   JR.). 

THE  NATIONAL  DISPENSATORY:  Containing  the  Natural  History,  Chemistry, 
Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in  the  latest  Phar- 
macopoeias of  the  United  States,  Great  Britian  and  Germany,  with  numerous  references 
to  the  French  Codex.  Fifth  edition,  revised  and  enlarged  in  accordance  with  and  em- 
bracing the  new  U.  S.  Pharmacopoeia,  Seventh  Decennial  Revision.  With  Supplement 
containing  the  new  edition  of  the  National  Formulary.  In  one  magnificent  imperial 
octavo  volume  of  2025  pages,  with  320  engravings  Cloth,  §7. 25 ;  leather,  §8.  With 
ready  reference  Thumb-letter  Index.     Cloth,  §7.75  ;  leather,  §8.50.     Just  ready. 

STIMSON   (LEWIS  A.).     A  MANUAL   OF  OPERATIVE  SURGERY.     New 

(3d)  edition.  In  one  royal  12mo.  volume  of  614  pages,  with  306  engravings.  Just  ready. 
Cloth,  §3.75. 

A  TREATISE  ON  FRACTURES  AND  DISLOCATIONS.     In  two  hand- 


some octavo  volumes.  Vol.  I.,  Fractures,  582  pages,  360  engravings.  Vol  II.,  Dislo- 
cations, 540  pages,  163  engravings.  Complete  work,  cloth,  §5.50 ;  leather,  §7.50.  Either 
volume  separately,  cloth,  §3 ;  leather,  §4. 

STUDENTS'  QUIZ  SERIES.  A  New  Series  of  Manuals  in  question  and  answer  for 
Students  and  Practitioners,  covering  the  essentials  of  medical  science.  Thirteen  volumes, 
pocket  size,  convenient,  authoritative,  well  illustrated,  handsomely  bound  in  limp  cloth, 
and  issued  at  a  low  price.  1.  Anatomy  (double  number);  2.  Physiology;  3.  Chemistry 
and  Physics ;  4.  Histology,  Pathology  and  Bacteriology ;  5.  Materia  Medica  and  Thera- 
peutics ;  6.  Practice  of  Medicine ;  7.  Surgery  (double  number) ;  8.  Genito-Urinary  and 
Venereal  Diseases ;  9.  Diseases  of  the  Skin ;  10.  Diseases  of  the  Eye,  Ear,  Throat  and 
Nose;  11.  Obstetrics;  12.  Gynecology;  13.  Diseases  of  Children.  Price,  §1  each,  except 
Nos.  1  and  7,  Anatomy  and  Surgery,  which  being  double  numbers  are  priced  at  §1.75  each- 
Full  specimen  circular  on  application  to  publishers. 

STUDENTS'  SERIES  OF  MANUALS.  A  Series  of  Fifteen  Manuals  by  Eminent 
Teachers  or  Examiners.  The  volumes  are  pocket-size  12mos.  of  from  300-540  pages,  pro- 
fusely illustrated,  and  bound  in  red  limp  cloth.  The  following  volumes  may  now  be 
announced:  Herman's  First  Lines  in  Midwifery,  §1.25;  Luff's  Manual  of  Chemistry, 
§2;  Bruce's  Materia  Medica  and  Therapeutics  i  fifth  edition),  §1.50;  Treves'  Manual  of 
Surgery  (monographs  by  33  leading  surgeons),  3  volumes,  per  set,  §6;  Bell's  Compara- 
tive Anatomy  and  Physiology,  §2 ;  Robertson's  Physiological  Physics,  §2 ;  Gould's 
Surgical  Diagnosis,  §2;  Klein's  Elements  of  Histology  (4th  edition),  §1.75;  Pepper's 
Surgical  Pathology,  §2;  Treves'  Surgical  Applied  Anatomy,  §2;  Power's  Human 
Physiology  (2d  edition1,  §1.50;  Ralfe's  Clinical  Chemistry,  §1.50;  and  Clarke  and 
Lockwood's  Dissector's  Manual,  §1.50 

For  separate  notices,  see  under  various  authors'  names. 

STURGES  (OCTAVIUS).  AN  INTRODUCTION  TO  THE  STUDY  OF  CLIN- 
ICAL MEDICINE.     In  one  12mo.  volume.     Cloth,  §1.25. 

SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE  OVARIES 
AND  FALLOPIAN  TUBES.  Including  Abdominal  Pregnancy.  In  one  12mo.  vol- 
ume of  513  pages,  with  119  engravings  and  5  colored  plates.     Cloth,  §3. 

TUMORS,  INNOCENT  AND  MALIGNANT.     Their  Clinical  Features  and 


Appropriate  Treatment.     In  one  8vo.  volume  of  526  pages,  with  250  engravings  and 
9  full-page  plates.     Cloth,  §4.50. 

TAIT  (LAWSON).  DISEASES  OF  WOMEN  AND  ABDOMINAL  SURGERY. 
In  two  handsome  octavo  volumes.  Vol.  I.  contains  546  pages  and  3  plates.  Cloth,  §3. 
Vol.  II.,  preparing, 

TANNER  (THOMAS  HAWKES).  ON  THE  SIGNS  AND  DISEASES  OF 
PREGNANCY.  From  the  second  English  edition.  In  one  octavo  volume  of  490  pages, 
with  4  colored  plates  and  16  engravings.     Cloth,  §4.25. 

TAYLOR  (ALFRED  SA  MEDICAL  JURISPRUDENCE.  Eleventh  American 
from  the  twelfth  English  edition,  specially  revised  by  Clark  Bell,  Esq.,  of  the  N.  Y. 
Bar.     In  one  octavo  vol.  of  787  pages,  with  56  engravings.     Cloth,  §4.50;  leather,  §5.50. . 


Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  III  Fifth  Ave.  (cor.  18th  St.). 


LEA    BROTHERS    &     CO.'  S    PUBLICATIONS.  15 

TAYLOR  (ALFRED  S.).  ON  POISONS  IN  RELATION  TO  MEDICINE 
AND  MEDICAL  JURISPRUDENCE.  Third  American  from  the  third  London 
edition.  Jn  one  8vo.  volume  of  788  pages,  with  104  illustrations.  Cloth,  §5.50; 
leather,  $6.50. 

TAYLOR  (ROBERT  W.).  THE  PATHOLOGY  AND  TREATMENT  OF 
VENEREAL  DISEASES.  In  one  very  handsome  octavo  volume  of  1002  pages,  -with 
230  engravings  and  7  colored  plates.     Cloth,  55 ;  leather,  $6.     Net. 

A    CLINICAL    ATLAS    OF    VENEREAL   AND    SKIN    DISEASES. 


Including  Diagnosis,  Prognosis  and  Treatment.  In  eight  large  folio  parts,  measuring 
14  x  18  inches,  and  comprising  213  beautiful  figures  on  58  full-page  chromo-lithographic 
plates,  85  fine  engravings,  and  425  pages  of  text.  Complete  work  now  ready.  Price  per 
part,  sewed  in  heavy  embossed  paper,  82.50.  Bound  in  one  volume,  half  Russia,  827 ; 
half  Turkey  Morocco,  828.  For  sale  by  subscription  only.  Address  the  publishers.  Spec- 
imen plates  by  mail  on  receipt  of  10  cents. 

IMPOTENCE  AND  STERILITY.    In  one  octavo  volume.    In  active  preparation. 


TAYLOR  (SEYMOUR) .  INDEX  OF  MEDICINE.  A  Manual  for  the  use  of  Senior 
Students  and  others.    In  one  large  12mo.  volume  of  802  pages.     Cloth,  8375. 

THOMAS  (T.  GAILLARD)  AND  MUNDE  (PAUL  P.).  A  PRACTICAL 
TREATISE  ON  THE  DISEASES  OF  WOMEN.  Sixth  edition,  thoroughly 
revised  by  Patjx  F.  Munde,  M.  D.  In  one  large  and  handsome  octavo  volume  of  824 
pages,  with  347  engravings.   Cloth,  85 ;  leather,  $6. 

THOMPSON  (SIR  HENRY).  CLINICAL  LECTURES  ON  DISEASES  OF 
THE  URINARY  ORGANS.  Second  and  revised  edition.  In  one  octavo  volume  of 
203  pages,  with  25  engravings.     Cloth,  82.25. 

THOMPSON  (SIR  HENRY).  THE  PATHOLOGY  AND  TREATMENT  OF 
STRICTURE  OF  THE  URETHRA  AND  URINARY  FISTULJE.  _  From  the 
third  English  edition.  In  one  octavo  volume  of  359  pages,  with  47  engravings  and  3 
lithographic  plates.     Cloth,  §3.50. 

TODD  (ROBERT  BENTLEY).  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.     In  one  8vo.  volume  of  320  pages.    Cloth,  82.50. 

TREVES  (FREDERICK).  OPERATIVE  SURGERY.  In  two  8vo.  volumes  con- 
taining 1550  pages,  with  422  illustrations.     Cloth,  89  ;  leather,  $11. 


A  SYSTEM  OF  SURGERY.  In  Contributions  by  Twenty-five  English  Sur- 
geons. In  two  large  octavo  volumes,  containing  2322  pages,  with  950  engravings  and 
4  full  page  plates.     Per  volume,  cloth,  88.     Just  ready. 

A  MANUAL  OF  SURGERY.    In  Treatises  by  33  leading  surgeons.     Three 


12mo.  volumes,  containing  1866  pages,  with  213  engravings.     Price  per  set,  86.     See  Stu- 
dents' Series  of  Manuals,  page  14. 

THE  STUDENTS'  HANDBOOK  OF  SURGICAL  OPERATIONS.    In 


one  12mo.  volume  of  508  pages,  with  94  illustrations.     Cloth,  §2.50. 

SURGICAL  APPLIED   ANATOMY.    In  one  12mo.  volume  of  540  pages, 


with  61  engravings.     Cloth,  82.     See  Students'  Series  of  Manuals,  page  14. 

INTESTINAL  OBSTRUCTION    In  one  12mo.  volume  of  522  pages,  with  60 


illustrations.     Cloth,  82.     See  Series  of  Clinical  Manuals,  page  13. 

TUKE  (DANIEL  HACK).  THE  INFLUENCE  OF  THE  MIND  UPON  THE 
BODY  IN  HEALTH  AND  DISEASE.  Second  edition.  In  one  8vo.  volume  of 
467  pages,  with  2  colored  plates.     Cloth,  83. 

VAUGHAN  (VICTOR  C.)  AND  NOVY  (FREDERICK  G.).  PTOMAINS, 
LEU  CO  MAINS,  TOXINS  AND  ANTITOXINS,  or  the  Chemical  Factors  in  the 
Causation  of  Disease.  Xew  (3d)  edition.  In  one  12mo.  volume  of  603  pages.  Cloth,  83. 
Just  ready. 

Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  III  Fifth  Ave.  (cor.  18th  St.). 


16  LEA    BROTHERS    &     CO.'  S    PUBLICATIONS. 

VISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1897.  Four 
styles:  Weekly  (dated  for  30  patients) ;  Monthly  (undated  for  120  patients  per  month) ; 
Perpetual  (undated  for  30  patients  each  week) ;  and  Perpetual  (undated  for  60  patients 
each  week).  The  60-patient  book  consists  of  256  pages  of  assorted  blanks.  The  first 
three  styles  contain  32  pages  of  important  data,  thoroughly  revised,  and  160  pages  of 
assorted  blanks.  Each  in  one  volume,  price,  $1.25.  With  thumb-letter  index  for  quick 
use,  25  cents  extra-  Special  rates  to  advance-paying  subscribers  to  The  Medical  News 
or  The  American  Journal  op  the  Medical  Sciences,  or  both.    See  page  1. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND  PRAC- 
TICE OF  PHYSIC.  A  new  American  from  the  fifth  and  enlarged  English  edition, 
with  additions  by  H.  Hartshorne,  M.D.  In  two  large  8vo.  volumes  of  1840  pages,  with 
190  engravings.     Cloth,  $9  ;  leather,  $11. 

WELLS  (J.  SOELBERG).  A  TREATISE  ON  THE  DISEASES  OF  THE 
EYE.     In  one  large  and  handsome  octavo  volume. 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR  TO 
WOMEN.  Third  American  from  the  third  English  edition.  In  one  octavo  volume  of 
543  pages.     Cloth,  $3.75;  leather,  $4.75. 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 


HOOD.    In  one  small  12mo.  volume  of  127  pages.     Cloth,  $1. 

WHARTON  (HENRY  R.).  MINOR  SURGERY  AND  BANDAGING.  New  (3d) 
edition.  In  one  12mo.  volume  of  594  pages,  with  475  engravings,  many  of  which  are 
photographic.     Cloth,  $3.     Just  ready. 

WHITLA  (WILLIAM).  DICTIONARY  OF  TREATMENT,  OR  THERA- 
PEUTIC INDEX.  Including  Medical  and  Surgical  Therapeutics.  In  one  square 
octavo  volume  of  917  pages.     Cloth,  $4. 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY.  A  new  and 
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